Who is completing this form

First Name

Last Name

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Email Address

Attendee Details

Attendee Email

Attendee First Name

Attendee Last Name

Attendee Phone Number

Title/Rank/Credentials

Street Address

City/Town

State / Province

Country

Zip/Postal Code

Emergency Contact

Emergency Phone Number

Agency / Organization Size - How big is your agency?

Which area to you primarily represent

What type of areas does your agency/organization predominately serve?

Age - Which category below includes your age?

Race - Which of the following best describes you? Select one

Indicate any special dietary needs

ADA Accommodations: List any special disability accommodations that will help ensure full participation

If meeting planners have questions, regarding requested accommodation, what is the best way to reach you prior to the start of the event?

How many CIT International Conferences have your attended (including this year)?

How did you hear about the CIT International Conference

Do you give permission for your contact information to be shared with our vendors/sponsors

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Packages

CIT Coordinator's Certification Course - $375

Continuing Education (For Licensed Clinicians Only) - $55

Expanding Your Range of Resilience - FREE

VA Roundtable 2.0 - FREE

Strengthen the Voice of Community Partners – FREE

Payment Section

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