Leadership Roundtable Registration Form

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Email the AGTS Office of Institutional & Alumni Relations: alumni@agts.edu

Conferences: Critical Incident Stress Management Seminar

A certification seminar that will teach you how to respond to emergency personnel and victims impacted by crisis events.

For: emergency personnel, ministers, chaplains, caregivers, etc.

When: October 29-30, 2004; Friday, 2-10 p.m.; Saturday, 8 a.m.-5 p.m.

Where: Assemblies of God Theological Seminary, 1435 North Glenstone, Springfield, Missouri, (southwest corner of Glenstone and Division)

Price: $75, includes training book and certificate ($45 for CoxHealth employees.)

Instructor: Mr. David Hoover, B.A., EMT-P, Trained Trainer for International Critical Incident Stress Foundations

Registration: Use the form below or register by phone at 417-268-1044. Registration deadline is October 15. Seminar is limited to first 75.

Credit Option: Participants may be eligible for a graduate credit option through AGTS. Contact the AGTS Continuing Education Office atagts-ext@agts.eduor 417-268-1044.

If taking this course for graduate credit, you must fill out the Continuing Education Course Selection Form in addition to this form.

Name:

Address:

Home Phone:

Work Phone:

Fax:

Email:

If registering persons in addition to the name above, please include the names of additional registrants here:

Registration

$ 75 x
($45 for CoxHealth Employees) # of persons = $

Graduate Credit: $335/ credit hour, 1 credit hour options. (Conference fee included.) $30 Required deposit # of persons = $
[Only if you want Graduate Credit. If taking this course for graduate credit, you must fill out the Continuing Education Course Reservation Form in addition to this form]

Total = $

How do you plan to pay? Visa MasterCard Discover

This form is to be used for credit card payments only. For payment by check, please print this completed form and mail it along with your check to the Continuing Education Office:

AGTS Continuing Education
1435 N. Glenstone Avenue
Springfield, MO 65802

If paying by credit card, complete the following:

Credit Card Number:

Expiration Date:

Verification Code: What is the verification code?

Name as it appears on credit card:

Daytime phone number:

*Registration fee included in graduate credit tuition. Additional registration information will be requested from those wishing to take the course for graduate credit.

Updated: Tuesday, January 18, 2011 2:34 PM