Registration Form

 

 

 

 

 

Information Processing &
Emotional Regulation:

Presented by PACE Place, Advance Therapy & ConnectorRxTM

For details, click on Emotional Regulation Strategies for Parents - Lino Lakes, MN.

The free Seminar is Monday, February 22nd, 2010 in Lino Lakes, MN. 

Dr. Calouri, Ph.D. and Eric Hamblen will present information on how an individual's ability to process information using specific areas of the brain impacts emotional regulation and the ability to learn.

 

They will also describe and demonstrate the ConnectorRxTM and discuss strategies that can be used at home, in the school, and in the community, helping the child gain competence in all environments. 

The seminar will be held at:
Advance Therapy
6776 Lake Drive, Suite 220
Lino Lakes, MN 55014


Registration will be completed by phone with Deb Crowell after

receipt of this online notification

Step 1:  Registrant Information

Registrant #1 Information

(*required for confirmation) 

 

*First Name    

 

*Last Name   

 

*Phone Number: Home 

Phone Number: Cell  

 

*E-Mail 

 

*Mailing Address

 

*City    *State *ZIP

 

 

Registrant #2 Information

(*required for confirmation of Registrant #2)

*First Name    

 

*Last Name   

 

*Phone Number: Home 

Phone Number: Cell  

 

*E-Mail 

 

If different from Registrant #1:

Mailing Address 

 

City    State ZIP

 

 

Step 2:  Registrant Profile

(optional)

 

Please tell us a little about you or your family so that we can make the seminar as effective for you as possible.

1.  About you

       Parent

       Professional (please describe)

       Both

 

2. For those with  special needs children, please give the name(s), age(s) and diagnosis.

    Name     Age  Diagnosis

    Name     Age  Diagnosis

    Name     Age  Diagnosis

 

    Please also list any siblings name(s) and age(s).

    Name     Age

    Name     Age

    Name     Age

    Name     Age

    

3. About your child(ren) at home or you work with (please check all that  apply)

 1-3                  M    F

 4-6                  M    F

 7-10                M    F

            11-18              M    F

 

4. Are you attending this conference with:

Spouse

Alone

Other

 

5. Have you attended a PACE Game Day or Seminar Series in the past?

Yes

No

 

Note:  If you are sent to an error page, check to be sure the required fields and options have been filled out. 

The required fields are:

    Registration Information: First and Last Name, Home Phone, email and

            mailing address. 

    Only the First Registrant is required.

 

Click     to complete your registration!

 

Please call Deb Crowell, Office Manager at 503-356-8334 x 6# if you have any further questions about the seminar on Emotional Regulation: Strategies for Parents & Professionals or about PACE Place, Inc.

   
 

 

 

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PACE Place, Inc.

2360SW 170thAve
Beaverton, OR 97006

Phone: (503) 356-8334