Federation of Families of South Carolina
Parent Leadership Training
September 19-20, 2014
One form per registration
Please print or type.
Name: ________________________________________________________________________
Mailing Address: ____________________________________________________________________
____________________________________________________________________________________
County:____________________________________________________________________________
Phone: ___________________________________Cell Number:______________________________
Email address: ______________________________________________________________________
Race: (optional-to help us achieve diversity)
African-American
Latino
Asian
White
Native American
Other:_______________________________
Are you a Parent/Caregiver Professional Both
Signature: ___________________________________________ Date:_________________________
Registration Deadline: September 12, 2014
Send registration form to:
Federation of Families of South Carolina
810 Dutch Square Blvd, Suite 205
Columbia, South Carolina 29210
Local 803.772.5210
Toll Free 866.779.0402
Or email to Pheobe.malloy@fedfamsc.org or sarah.rolf@fedfamsc.org
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Luncheon choice: __Standard __Vegetarian __Other_____________________________________
Accessibility assistance: See general information
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The purpose of this training is to provide family members of children with emotional, behavioral or mental health needs and/or substance abuse disorders with the skills necessary to become a better advocate for their child.
The following criteria are required to attend this training:
1.
The individual must be the parent* of a child with emotional, behavioral or mental health needs and/or substance abuse disorders.
2.
The parent is able to attend the full training and has a willingness to become a better advocate for their child.
3.
The parent agrees to provide the Federation of Families of South Carolina with updates on their child and how the training has been of benefit to the child and family.
I am agreeing to work with the Federation as a community volunteer and to facilitate engaging other family members in the community and establishing a Family Support Network for any family members who would like to participate or receive education and support.
*Primary caregiver of child (biological, adoptive, foster or grandparent or other individual providing primary care to the child)
I, ___________________________________________________, have read and understand the criteria to attend the Leadership training. I agree that I meet the criteria and will complete the requirements listed above.
_______________________________________________ ___________________
Signature Date
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Name_________________________________________________________________________
Address_______________________________________________________________________
_______________________________________________________________________
County:_______________________________________________________________________
Telephone: Home________________________ Cell___________________________________
E-mail address_________________________________________________________________
I would like to participate in the upcoming Leadership Training that will be provided by the
Federation of Families of South Carolina. I understand that by agreeing to participate, the
Federation of Families of South Carolina will agree to cover expenses of the training. In return I am agreeing to provide the Federation of Families of South Carolina with updates on my child and how the training has been of benefit to my child and my family.
I am aware that the hotel is a nonsmoking facility. Lodging is double occupancy and is being provided only for the applicant listed on the application. (If you prefer a private room, there is a charge of $40.00, payable in advance to the Federation of Families.)
If for any reason I am unable to participate in the training I agree to notify the Federation at least 24 hours in advance so that they will be able to make necessary changes to registrations and other expenses that otherwise would have to be paid even though I was unable to attend.
____________________________________________ ___________________________
Signature of Participant Date
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