1. Name          
2. Agency Name
3. Address
4. Contact telephone
5. Course titleDate(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: Intermediate Child Abuse (reported as 2105 with TCLEOSE)
Tuition: $25.00
Start/End Date: Jan 13-15 or April 14-16 or July 14-16 or Oct 13-15, 2010 (24-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)