WJCIA CONFERENCE REGISTRATION FORM

Basic Intake Training


Participant's First Name:
Participant's Last Name:
Participant's Title:
Participant's E-mail Address:
(Confirmation of registration will be sent to this address.)
Agency Name:
Agency Address:
City: State: Zip:
Phone:
Fax:
Supervisor's Name:
Supervisor's E-mail Address:
Supervisor's Phone:
Date on line training completed:
If on line training not completed, date it will be:
Dates of in person training you are registering for:
Other information you would like us to know:

 

Registration contact:
Melissa Williams – MWILLIAM@co.washburn.wi.us
Washburn County HHSD
PO Box 250
Shell Lake, WI 54871
Phone: 715-468-4766