Health/Senior Training (Oct. 15-16, 2009) Tampa, FL

Answer questions as they relate to you. For most answers, check the boxes most applicable to you or fill in the blanks. REGISTRATION DEADLINE - SEPTEMBER 14, 2009

The Health/Senior Training will be held at the Embassy Suites Hotel -USF/Busch Gardens, 3705 Spectrum Blvd, Tampa FL, Thursday-Friday, October 15-16, 2009. You will be responsible for making your own hotel reservations (see Recommended Hotel Accommodations). Hotel reservations must be received by SEPTEMBER 14, 2009.

If you have any questions please contact Kathy Grunewald or Sharon Ferguson at the email addresses or telephone numbers listed below.

Thank you.

Kathy Grunewald
Statewide Director of Training
Florida Legal Services, Inc.
kathy@floridalegal.org
(850) 385-7900

Sharon Ferguson
Training Coordinator
Florida Legal Services, Inc.
sharon@floridalegal.org
(904) 768-8561

Please provide the following (*required)

First Name*

Last Name*

Email*

Program Information

1.	Legal services/Legal Aid program name (Please provide program's full name, DO NOT use acronyms)

2.	Program Mailing Address

3.	Phone Number

4.	Fax Number

5.	I am registering as a

	Faculty Member (Skip to Q. 9)
	Training Participant

General Information

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
	Other:

7.	List your YEARS in practice:

8.	List your YEARS in legal aid (including with your CURRENT organization):

Dietary Needs/Special Consideration

Please Note: We cannot guarantee true vegetarian/vegan meals. Nor can we provide or guarantee food is free of any specific allergen. Any participant likely to suffer a severe anaphylactic reaction to an allergen or on a restrictive diet should consider bringing their own food. Each guest room at the Embassy Suites is equipped with a microwave and refrigerator.

9.	My special dietary needs are

	None
	Vegetarian (No animal products, only vegetables, fruits, and sometimes eggs or dairy products)
	Vegan (Strict - no animal food or dairy products)

10.	Personal Consideration(s) - Please describe:

Recommended Hotel Accommodations

A rooming block has been reserved at the Embassy Suites-USF/Busch Gardens, Tampa, FL. Reservations can be made by emailing Ermy Rosales at ermy.rosales@jqh.com or by calling Ms. Rosales at 813-977-7066 (Reservation Department). To receive the group rate, you must identify yourself as part of the "Health/Senior" training. Room rates are $104.00 - $124.00 per night, based upon occupancy. Reservations must be made by SEPTEMBER 14, 2009. Reservations made after this date will be accepted on a space available basis.

Cancellations must be made by 4:00 p.m. day before arrival. Please confirm the cancellation policy when making your reservation.

All hotel rooms will be master billed to Florida Legal Services. FLS will then in turn, invoice your program. A credit card or cash deposit will be needed at check -in to cover incidentals (i.e. telephone calls, internet access, room service, etc.).

Thank You

Please be sure you have provided a viable work email address, all future communications will be through emails.

You will receive a confirmation email once your registration is completed. Occasionally due to email restrictions this confirmation may not be accepted by your email server. DO NOT submit another registration. Contact our Training Coordinator, Sharon Ferguson at sharon@floridalegal.org to confirm whether your registration was received.

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