ACEPT 2019 Practicum Fair Site Registration Form
Friday December 6, 2019
Location: Roosevelt University, Second Floor
430 South Michigan Avenue at Congress
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.
Site Street Address
City, State, and ZIP Code
Please tell us a little about your training site:
Name of Training Director
Phone Number of Training Director
Email Address of Training Director
Name of first attending supervisor (limit of 2)
Name of second attending supervisor (limit of 2)
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.
Please check all levels/types of practicum offered at your site:
Advanced Therapy Externship/Practicum
Advanced Diagnostic Externship/Practicum
I/O Psychology Externship/Practicum
Art Therapy Externship/Practicum
Please select your type of registration:
My organization is currently an ACEPT member
My organization is not an ACEPT member and I am sending my $50 registration fee separately by check in the mail
My organization is not an ACEPT member and I would like to pay the $50 registration fee by Paypal (please click the link attached to the narrative after you submit your responses)
My organization is not an ACEPT member and I will be paying the $50 registration fee at the Practicum Fair
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.
If you are attending the CE presentation - lunch will be provided. Please indicate any special requests for lunch.
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.
Send me a copy of my responses.
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