Understanding the Impact of Intimate Partner Violence by rwd15578

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									                    Understanding the Impact of
       Intimate Partner Violence: Helping Social Workers To
       Better Intervene - Train-the-Trainer Training Program
                                              Registration Form

                                       Date: February 24-25, 2010
                                           Time : 8:30 – 4 :30
                               Location: Wu Conference Centre, 6 Duffie Dr.
                                    UNB, Fredericton, New Brunswick

Please fill in the following information and return by email, fax, or post.

PARTICIPANT INFORMATION
Na m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Title/Workplace: ___________________________________________________________________
Address: __________________________________________________________________________
Email: ___________________________________________________________________________
Telephone: _______________________________________________________________________
Fax: ______________________________________________________________________________

                                          This session is in English.
Do you have any dietary restrictions/allergies? (Please specify) _________________________
_________________________________________________________________________________

Registration Fee:
The registration fee includes a hard copy and an electronic copy of the training manual and the ac-
companying video, lunches, and nutrition breaks. Cheques should be made payable to the Muriel
McQueen Fergusson Centre. Register ASAP as space is limited. Refunds unavailable. If you
require accommodations, a block of rooms is being held at the Fredericton Inn until February 2
(http://www.frederictoninn.nb.ca/). Please call 1-800-561-8777 to make your reservations. Please
note that participants are responsible for their own accommodations.
____ I have enclosed a cheque or money order in the amount of $385.00
____ Please invoice my workplace: ___________________________________________
                                    (provide contact name & address)

          Please return this form to: Muriel McQueen Fergusson Centre,
             P.O. Box 4400, Fredericton, New Brunswick, E3B 5A3 or
                     email: fvrc@unb.ca / fax: 506.453-4788
                For more information: telephone: 506.453-3595;
                                                 www.unbf.ca/arts/CFVR

								
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