REGISTRATION FORM
27thANNIVERSARY CONFERENCE ON PROMOTING HEALTHY ATTACHMENTS
NOVEMBER 20-21, 2017
WILSON LODGE, OGLEBAY RESORT and CONVENTION CENTER, WHEELING, WEST VIRGINIA
Register early. Seating is limited.
Please submit a separate form for each person attending.
DEADLINE FOR RESERVATIONS: FRIDAY, NOV. 10, 2017
Name /Address /
City/State/Zip /
Phone / E-Mail
Click on boxesin left column below for sessions you will attend for registration purposes and CE certificates.
“X” / Session / RateMon., Nov. 20
AND
Tue., Nov. 21 / CONFERENCE DISCOUNTED RATE: Day-time Trainings (Mon. and Tue., Nov. 20-21, 8:30 AM - 4:00 PM each day (Monday evening training not included.) Make selections below. / $118.00
Both Days
Mon., Nov. 20OR Tue., Nov. 21 / DAYTIME SESSIONS - 8:30 AM-4:00 PM
(6 CE'S PER DAY) Make selections below. / $68.00
One Day Only
MON., NOV. 20, 8:30 AM – 4:00 PM (6 CE Hours)
- Let’s Make SBIRT a VITAL SIGN (M. Frank Beck and Nick Ceglia) 8:30-10:15 AM
(1.75 CE Hours) - Dreamland: The True Tale of America’s Opiate Epidemic (Sam Quinones)
- The Impact of the Opiate Crisis on Families and How to Help (Tim Schaffner)
MON., NOV. 20, 4:30-8:45 PM – Buffet and Learning Session
- The Effects of Heroin on Society (Maureen Dee) (3 CE Hours)
TUES., NOV. 21, 8:30 AM-4:00 PM
- Drugs, Alcohol, Pregnancy, and Parenting (IraJ. Chasnoff)
8:30-11:45 AM(3 CE Hours) - The Mystery of Risk: The Impact of Prenatal Substance Exposure on the Growing Child(Ira J. Chasnoff)12:45-4:00 PM (3 CE Hours)
OHIO NURSES, WV COUNSELORS, and ALL PACEs: Add $10/Day /
Please indicate the State and Licensure requested for CEs, if applicable.)(See brochure.) /
Festival of Lights Trolley Ride (Mon., Nov. 20, 9:00 PM) / $10.00
ENTER TOTAL REGISTRATION FEES
(Includes morning refreshments, lunch, and afternoon snacks.)
REFUND POLICY: All refunds will be assessed $25.00. No refunds after Friday,
Oct. 20, 2017.Visit our web site: /
In case of an emergency, the Conference reserves the right to substitute another presenter.
Fees cannot be adjusted for partial attendance or lunch.
Attendees must be 18 years of age or older.
Lunch provided from 11:45 AM – 12:45 PM each day.
Return this form to: DeDe Kidder–
Make check or money order payable to: Jefferson County Department of Job & Family Services.
Mail registration form with paymentto: Michele Santin, Director
Office of Catholic Charities& Social Concerns, Diocese of Steubenville, P. O. Box 969, Steubenville, OH 43952
Registration is not complete until payment is received.
Contact Information: Michele Santin or DeDe Kidder – 740-282-3631
Please let us know if you require a Special Diet Lunch by checking one box below.
Vegetarian Gluten Free
27th ANNIVERSARY CONFERENCE ON PROMOTING HEALTHY ATTACHMENTS
NOVEMBER 20-21, 2017
WILSON LODGE, OGLEBAY RESORT and CONVENTION CENTER, WHEELING, WEST VIRGINIA
REQUEST FOR CONTINUING EDUCATION HOURS
Up to 15 total hours available for the following licensures.
PLEASE CLICK ON THE BOXES BELOW THAT APPLY FOR YOUR REQUESTED CEs.
An “X” will automatically appear in the box.
INSERT YOUR NAME IN THE BOX AT THE BOTTOM OF THE PAGE.
Approved for:Counselors and Social Workersby the State of Ohio Counselor, Social Worker, and Marriage and Family Therapists Board. Neil Kennedy Recovery Centers, Provider No. RCS050802. Approved for 15.0 Clock Hours.
Approved for: CDCA, LCDC II/III, LICDC, LICDC-CS by the State of Ohio Chemical Dependency Professionals Board. Neil Kennedy Recover Centers, Provider No. 04-1416-13PVN–C.S.P.R. Approved for 15.0 Clock Hours.
Ohio RNs and LPNs CE hours have been approved by the Ohio Mental Health & Addiction Services Committee, an approved provider of Continuing Education for RNs and LPNs for the Ohio Board of Nursing and has awarded up to fifteen (15) CE contact hours per OBN003 92.
CE’s for WV Social Workers are provided through the co-sponsorship of the Children’s Home Society of West Virginia. WV Board of Social Work Examiners, Provider No. 490030.
WV Counselor CE's provided by the Office of Family and Social Concerns, an approved provider for continuing education hours applicable to WV Counselors, WVBEC - 112116.
Catholic Charities, Diocese of Steubenville, is an approved provider for fifteen (15) CE hours for West Virginia Nurses. WV Board of Examiners for Registered Professional Nurses, WV2016-0629RN.
PA LSW/LCSW, LPC, and LMFT: This program is offered for fifteen (15) hours of social work continuing education through co-sponsorship of the Univ. of Pittsburgh’s School of Social Work, a Council on Social Work Education-accredited school and, therefore, a PA pre-approved provider of social work continuing education. These credit hours satisfy requirements for LSW/ LCSW, LPC, and LMFT biennial license renewal. Call 412-624-3711 for information on social work continuing education. NOTE: PA does not give CE hours in 15 minute increments; only 1.0, 1.5, 2.0, 2.5, 3.0 hours, etc; thus CEs for PA attendees Monday AM will be adjusted.
Belmont County, Ohio, Juvenile Courts, Guardian Ad Litems (GALS) ONLY: The three-hour evening training or each full day of training is approved for three (3) hours of continuing education satisfying Superintendence Rule 48 (Guardians Ad Litem.)
Jefferson County, Ohio, Juvenile Courts, Guardian Ad Litems (GALS) ONLY: The three-hour evening training or each full day of training is approved for three (3) hours of continuing education satisfying Superintendence Rule 48 (Guardians Ad Litem.)
Name Date