* Host Organization:  

* Contact Person:  

Title:  

* Address:  

* City:  

* Zip Code:  

* Phone Number: 

()

Fax Number: 

()

* E-Mail:  

* Workshop Title / Topic 1:  

* Workshop Title / Topic 2:  

* Who is this workshop being planned for: (Please check all that apply)  

Service Coordinators

Foster Parents

Parents

Parent Leaders

School Personnel

Teacher

Others (specify)

Workshop Dates Requested (Please list at least three potential dates, if your dates are flexible):

* Date 1:  

* Date 2:  

* Date 3:  

Workshop Time(s) Requested:

* Time 1:  

* Time 2:  

* Time 3:  

* Duration of Workshop:  

* Workshop Location:  

* Address:  

* City:  

* County:  

Room Number:  

Floor:  

Emergency Contact for Host Organization at time of Workshop (Name and Phone Number):

* Name:  

* Phone Number:  

()

* Please insure that the facility is handicap accessible.