ACEPT 2019 Practicum Fair Site Registration Form
Friday December 6, 2019
Location: Roosevelt University, Second Floor
430 South Michigan Avenue at Congress

Itinerary:
8:30-9am registration on 2nd floor
9-9:30am Breakfast and ACEPT guidelines presentation in room AUD244
9:30-12 ACEPT site table open to students and ACEPT guidelines presentations for students
12-12:30pm Break and Lunch for those who registered for the CE presentation (please note lunch is provided only for those attending the CE presentation)
12:30-2pm CE Presentation in room AUD244

PLEASE RSVP VIA THIS FORM BY NOVEMBER 22, 2019.
Email address *
Site Name
Your answer
Site Street Address
Your answer
City, State, and ZIP Code
Your answer
Please tell us a little about your training site:
Name of Training Director
Your answer
Phone Number of Training Director
Your answer
Email Address of Training Director
Your answer
Name of first attending supervisor (limit of 2)
Your answer
Name of second attending supervisor (limit of 2)
Your answer
If there are multiple programs at your site (i.e. a consortium or hospital with various tracks) please indicate the names here so we may seat your tables near one another.
Your answer
Please check all levels/types of practicum offered at your site:
Please select your type of registration:
Will you be staying to attend the CE presentation by Dr. Holly Passi titled "Psychotherapy with Military Veterans: Cultural Competence and Common Clinical Concerns" after the fair from 12:30-2:00pm (lunch provided beforehand)?
If you need CE's for attending the presentation, please give the name of the attending person or persons.
Your answer
If you are attending the CE presentation - lunch will be provided. Please indicate any special requests for lunch.
Thank you
Thank you for taking the time to complete the registration form. The next page will have information about the Practicum Fair as well as payment.
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