1. Name          
2.
Agency Name

3.
Address

4. Contact telephone
5. Course title
Date(Please submit which date)
6. Must list E-mail address

7.
Please print this page before submitting: (This confirms registration and equipment list needed for class)

Course: Crisis Intervention Training (reported as 3841 with TCLEOSE)
Tuition: $35.00
Start/End Date: Dec 21-22, 2009 or June 7-8 or Aug 2-3 or Nov 1-2, 2010 (16-hrs)
Start Time: 8:30 AM
Room#: TBA
Dress: Clothing suitable for classroom lecture
Material to Bring:
     Pen and paper
     TCLEOSE PID# (is required for credit)