DCF Subscription Series Registration Form
(for Department of Children and Families Staff ONLY)
One (1) Registrant per Form
Name:
Position:
Organization:  Department of Children and Families
 Work Address:
Street: City:
State: MA Zip: Email:
Work Phone: Cell or Home Phone (in case of snow):
Social Worker CE: LICSW LCSW   LSW  Reg. #:
MH Counselor CE:  Reg. #: OT Contact Hours
Nat'l Cert. Counselor CE Nurse Contact Hours Marriage & Family CE
Substance Abuse or LADC CE Psychologist CE     Educator Certificate

IMPORTANT! NEW LOCATION:

» You can register for a MAXIMUM of 3 workshops

 Courtyard by Marriott Billerica
270 Concord Road
Billerica, MA 01821
Phone: 978-670-7500

» You will NOT receive confirmation; assume you are registered

» You cannot cancel. If you cannot attend, send a substitute

» Print a copy of this form for your records

» Each workshop is from 9:00 am - 4:00 pm and offers 6 CE hours

 Click here for Directions
Select a Maximum 3 Workshop(s) Click on each workshop title to see description
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Contact us:  Community Program Innovations, Inc.
471 Broadway, Lynnfield, MA 01940		 Tel: 978-968-2781 Email Us