• Please provide the following information:

  First Name
  Last Name
  Title
  School or Organization
  Street Address
  Address (cont.)
  City
  State/Province
  Zip/Postal Code
  Country
  Work Phone
  E-mail

            Session #1 Choice  Choose one.... Mean Girls/Tough Boys Dating Violence Prevention:  Ohio's New Law for Schools Suicide/Bullycide

            Session #2 Choice  Choose one.... Diversity in Prevention Dating Violence Prevention:  Ohio's New Law Eating Disorders:  Affecting Guys & Girls

            Session #3 Choice  Choose one.... Restorative Justice/Cyberbullying Solutions Dating Violence Prevention:  Ohio's New Law Media Violence and Internet Addiction

            Certificate Req'd Select one..... Certificate/Contact Hours Only (no extra fee) CEU's Counselors, Social Workers, Nurses add $10 to registration  

            Payment Type Choose one.... Please bill me, I will pay with a check Please bill me, I will pay with a purchase order Credit Card/Paypal

            Additional information

            Required:  What is 5 + 4? (Prevents spam)

By submitting this form, you agree that:   Cancellations must be received in writing and received no less than 15 business days prior to the event for a refund. No refunds for cancellations received less than 15 days prior to event.   If an event is cancelled due to weather, your registration will be applied to the the make up event date.  No refunds for non-attendance if event is not cancelled by Campus Impact.  Campus Impact reserves the right to cancel an event due to reasons beyond our control, in which case, your choice of a full refund or credit towards future events will be provided.