Registration: Online Registration for Re-Broadcast of January -- 2006 Medicare Part D Webinar

1.

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2.

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3.

I am registering for the following event:

Re-Broadcast of the January 9, 2006 - "Medicare Part D" Webinar (This training event is archived)

4.

I agree that I will assist the sponsors of this event by completing a post-training questionnaire (feedback).

I agree

5.

I agree that service fees from ConferenceCall.com may apply. Based upon current charges, I understand total viewing is estimated at $20.79 for which cost I will be responsible.

I agree

6.

(Home) Address

7.

(Home) City / State / Zip

8.

(Home) Phone (include area code)

9.

Your role

Advocacy - Attorney: Staff Attorney (Senior - 3 or more years experience)

Advocacy - Attorney: Staff Attorney (Junior - 0 to 3 years experience)

Advocacy - Attorney: Director

Advocacy - Attorney: Supervising Attorney

Advocacy - Paralegal (Senior - 3 or more years experience)

Advocacy - Paralegal (Junior - 0 to 3 years experience)

Administration - Executive Director

Administration - Deputy Director

Administration - Managing Attorney

Pro-Bono Attorney (Private)

Summer Fellow

Support Staff - Legal Assistant

Other:

10.

Your Immediate Supervisor: Name

11.

Your Immediate Supervisor: Phone and Email

12.

Your Office Computer Technician (staff who can set up the web seminar on your computer): Name -

13.

Your Office Computer Technician (staff who can set up the web seminar on your computer): Phone and Email -

14.

List your YEARS of experience at your CURRENT organization:

15.

List your YEARS of experience in LEGAL SERVICES (including your CURRENT organization):

16.

Please select your Organization:

1000 Friends of Florida (Skip to Q. 31)

American Friends Service Committee (Skip to Q. 31)

Bay Area Legal Services, Inc. (Skip to Q. 17)

Brevard County Legal Aid, Inc. (Skip to Q. 31)

Coast to Coast Legal Aid of South Florida Inc. (Skip to Q. 31)

Community Law Program (Pro Bono Program) (Skip to Q. 31)

Community Legal Services of Mid-Florida, Inc. (Skip to Q. 18)

Florida Children's First, Inc. (Skip to Q. 31)

Florida Equal Justice Center, Inc. (Skip to Q. 31)

Florida Immigrant Advocacy Center (Skip to Q. 19)

Florida Institutional Legal Services, Inc. (Skip to Q. 31)

Florida Justice Institute, Inc. (Skip to Q. 31)

Florida Legal Services, Inc. (Skip to Q. 20)

Florida Rural Legal Services, Inc. (Skip to Q. 21)

Guardianship Program for Dade County (Skip to Q. 31)

Gulfcoast Legal Services, Inc. (Skip to Q. 22)

Heart of Florida Legal Aid Society, Inc. (Skip to Q. 31)

Jacksonville Area Legal Aid Inc. (Skip to Q. 23)

Lee County Legal Aid Society, Inc. (Skip to Q. 31)

Legal Advocacy Center of Central Florida, Inc. (Skip to Q. 31)

Legal Aid Foundation of the Tallahassee Bar Association (Skip to Q. 31)

Legal Aid of Manasota, Inc. (Skip to Q. 31)

Legal Aid Service of Broward County, Inc. (Skip to Q. 31)

Legal Aid Society of Collier County, Inc. (Skip to Q. 24)

Legal Aid Society of Palm Beach County, Inc. (Skip to Q. 25)

Legal Aid Society of the Dade County Bar Association (Skip to Q. 26)

Legal Aid Society of the Orange County Bar Association, Inc (Skip to Q. 31)

Legal Services of Greater Miami, Inc. (Skip to Q. 27)

Legal Services of North Florida, Inc. (Skip to Q. 28)

Northwest Florida Legal Services, Inc. (Skip to Q. 29)

Seminole County Bar Association Legal Aid Society, Inc. (Skip to Q. 31)

Southern Legal Counsel, Inc. (Skip to Q. 31)

St. Johns County Legal Aid (Skip to Q. 31)

Three Rivers Legal Services, Inc. (Skip to Q. 30)

Other: (Skip to Q. 31)

17.

Bay Area Legal Services, Inc. - Select your specific address:

18240 U.S. 301 South, P.O. Box 249, Wimauma, FL 33598 (Skip to Q. 31)

2600 Dr. Martin Luther King Street, Suite 401, St. Petersburg, FL 33704-2744 (Skip to Q. 31)

37718 Meridian Avenue, Dade City, FL 33525 (Skip to Q. 31)

701 Tillman Place, Suite 300, Plant City, FL 33566-7169 (Skip to Q. 31)

8406 Massachusetts Avenue, Suite B-2, New Port Richey, FL 34653-3130 (Skip to Q. 31)

Edgecomb Courthouse, Room 203, 800 E. Twiggs Street, Tampa, FL 33602 (Skip to Q. 31)

Riverbrook Professional Center, 829 W. Martin Luther King Blvd., Suite 200, Tampa, FL 33603 (Skip to Q. 31)

Other: (Skip to Q. 31)

18.

Community Legal Services of Mid-Florida, Inc. - Select your specific address:

128-A Orange Ave., Daytona FL 32114-4310 (Skip to Q. 31)

1036 West Amelia Street, Orlando, FL 32805-1408 (Skip to Q. 31)

1300 Highway 41 North, Suite A, Inverness, FL 34450-3984 (Skip to Q. 31)

216 S. 6th Street, Palatka, FL 32177-4607 (Skip to Q. 31)

222 SW Broadway Street, Ocala, FL 34474-4140 (Skip to Q. 31)

226 West Martin Street, Tavares, FL 32778-3812 (Skip to Q. 31)

315 Magnolia Avenue, Sanford, FL 32771-1915 (Skip to Q. 31)

51 West Fort Dade Avenue, Brooksville, FL 34601-2503 (Skip to Q. 31)

604-1 E. Moody Blvd., Bunnell, FL 32110 (Skip to Q. 31)

800 North Main Street, Kissimmee, FL 34744-4564 (Skip to Q. 31)

803 N. Fiske Boulevard, Cocoa, FL 32922-7323 (Skip to Q. 31)

Legal Assistance Programs For Children - Special Education Advocacy Project, 128 Orange Avenue, Daytona Beach, FL 32114 (Skip to Q. 31)

Other: (Skip to Q. 31)

19.

Florida Immigrant Advocacy Center - Select your specific address:

3000 Biscayne Boulevard, #400, Miami, FL 33137 (Skip to Q. 31)

P.O. Box 3808, Fort Pierce, FL 334948-3808 (Skip to Q. 31)

Legal Assistance Programs For Children - Unaccompanied Minors Project, 3000 Biscayne Boulevard, Suite 400, Miami, FL 33137 (Skip to Q. 31)

Other: (Skip to Q. 31)

20.

Florida Legal Services, Inc. - Select your specific address:

(Main Office) 2425 Torreya Drive, Tallahassee, FL 32303 (Skip to Q. 31)

(Migrant Farmworker Justice Project), 508 Lucerne Avenue, Lake Worth, FL 33460 (Skip to Q. 31)

(Resource Development) 16057 Tampa Palms Blvd., West #355, Tampa, FL 33647-2001 (Skip to Q. 31)

2066 Plainfield Avenue, Orange Park, FL 32073 (Skip to Q. 31)

3000 Biscayne Blvd., Suite 450, Miami, FL 33137 (Skip to Q. 31)

Legal Assistance Programs For Children - State Support Children's Impact Advocacy and Clearinghouse, 2066 Plainfield Avenue, Orange Park, FL 32073 (Skip to Q. 31)

Other: (Skip to Q. 31)

21.

Florida Rural Legal Services, Inc. - Select your specific address:

(Main Office) 963 E. Memorial Boulevard, Lakeland, FL 33801 (Skip to Q. 31)

1500 NW Avenue "L" Unit B, Belle Glade,FL 33430 (Skip to Q. 31)

210 South First Street, Immokalee, FL 34142 (Skip to Q. 31)

3210 Cleveland Avenue, P.O. Box 219, Ft. Myers, FL 33902-0219 (Skip to Q. 31)

350 E. Marion Avenue, Suite A 1017 and A1018, Charlotte County Justice Center, Punta Gorda, FL 33950 (Skip to Q. 31)

423 Fern Street, Suite 220, West Palm Beach, FL 33401 (Skip to Q. 31)

P.O. Box 4333, Ft. Pierce, FL 34948 (Skip to Q. 31)

Other: (Skip to Q. 31)

22.

Gulfcoast Legal Services, Inc, - Select your specific address:

430 - 12th Street West, Bradenton, FL 34205 (Skip to Q. 31)

Main Office, 641 First Street South, St. Petersburg, FL 33731 (Skip to Q. 31)

Glasser-Schoenbaum Human Services Center, 1750 17th Street, Unit I (Skip to Q. 31)

Other: (Skip to Q. 31)

23.

Jacksonville Area Legal Aid Inc. - Select your specific address:

126 W. Adams Street, Jacksonville, FL 32202 (Skip to Q. 31)

1107 Middleburg Avenue, P.O. Box 1999, Green Cove Springs, FL 32043-1999 (Skip to Q. 31)

Other: (Skip to Q. 31)

24.

Legal Aid Society of Collier County, Inc. - Select your specific address:

1402 West Market Road, Unit #A, Immokalee, FL 34142 (Skip to Q. 31)

4125 E. Tamiami Trial, Naples, FL 34112 (Skip to Q. 31)

Other: (Skip to Q. 31)

25.

Legal Aid Society of Palm Beach County, Inc. - Select your specific address:

Foster Children's Project, 423 Fern Street,Suite 200, West Palm Beach FL 33401-5694 (Skip to Q. 31)

Main Office, 423 Fern Street, Suite 200, West Palm Beach, FL 33401-5694 (Skip to Q. 31)

Western Communities Education Project, 141 South Main Street, Suite 101, Belle Glade, FL 33430 (Skip to Q. 31)

Legal Assistance Programs For Children - Educational Advocacy, 423 Fern Street, Suite 200, West Palm Beach, FL 33401-5694 (Skip to Q. 31)

Other: (Skip to Q. 31)

26.

Legal Aid Society of the Dade County Bar Association - Select your specific address:

123 NW First Avenue, 3rd Floor, Miami, FL 33128 (Skip to Q. 31)

(STOP Project), 175 NW First Avenue, 2nd Floor, Miami, FL 33128 (Skip to Q. 31)

100 Washington Avenue, 3rd Floor, Miami Beach, FL 33139 (Skip to Q. 31)

28905 S. Federal Highway, Homestead, FL 33189 (Skip to Q. 31)

Other: (Skip to Q. 31)

27.

Legal Services of Greater Miami, Inc. - Select your specific address:

3000 Biscayne Blvd. Suite 500, Miami FL 33137 (Skip to Q. 31)

Florida City/Homestead Neighborhood Center, 1600 NW 6th Court, Florida City, FL 33034 (Skip to Q. 31)

Blanche Morton-City of Hialeah Neighborhood Center, 300 East 1st Avenue, Room 109, Hialeah, FL 33010 (Skip to Q. 31)

Legal Services of the Florida Keys, 600 White Street, Key West, FL 33040 (Skip to Q. 31)

Liberty City - Miami Workers' Center, 6127 NW 7th Avenue, Miami, FL 33127 (Skip to Q. 31)

South Dade Law Center, 10720 Carribean Boulevard, Suite 400, Miami, FL 33189 (Skip to Q. 31)

Legal Assistance Programs For Children - Special Education Advocacy Project - Miami, 3000 Biscayne Boulevard, Suite 500, Miami, FL 33137-4129 (Skip to Q. 31)

Other: (Skip to Q. 31)

28.

Legal Services of North Florida, Inc. - Select your specific address:

8 West Jefferson Street, Suite 200, Quincy, FL 32351 (Skip to Q. 31)

Main Office, 2119 Delta Boulevard, Tallahassee, FL 32303 (Skip to Q. 31)

118 South Baylen South, Pensacola, FL 32501 (Skip to Q. 31)

133 Staff Drive, Suite B, Ft. Walton Beach, FL 32548 (Skip to Q. 31)

221 East 23rd Street, Suite B, Panama City, FL 32405 (Skip to Q. 31)

Legal Assistance Programs For Children - Teen Law Initiative, 2119 Delta Boulevard, Tallahassee, FL 32303-4220 (Skip to Q. 31)

Other: (Skip to Q. 31)

29.

Northwest Florida Legal Services, Inc. - Select your specific address:

5224 Willing Street, Milton, FL 32570 (Skip to Q. 31)

701 South J Street, Pensacola, FL 32501 (Skip to Q. 31)

Other: (Skip to Q. 31)

30.

Three Rivers Legal Services, Inc. - Select your specific address:

123 W. Adams Street, Suite 101, Jacksonville, FL 32202 (Skip to Q. 31)

901 NW 8th Avenue, Ste. D-5, Gainesville, FL 32601 (Skip to Q. 31)

P.O. Drawer 3067, 853 SW Sisters Welcome Road, Lake City, FL 32056-3067 (Skip to Q. 31)

Other: (Skip to Q. 31)

31.

List Your PRIMARY Area of Expertise:

32.

List Your SECONDARY Area of Expertise:

33.

Communication between FLS and You

I agree that the primary form of communication will be via email

I do not have an email address, however, I will list how I can be contacted during business hours.

34.

My Email address is

35.

I can be contacted during business hours by the following:

36.

Please make certain your computer is ONLINE - then submit your registration. Your registration will not be properly submitted unless your computer is online with the Internet.