School/Organization:
Address:


Phone:
Fax:
Contact Person:
E-Mail Address:

Participants who will attend the 2-day (DLAM) or 1-day (FCB) workshop:

	Name	Title/Position
1.
2.
3.
4.
5.

Date that you would prefer to attend:

*CEU credit (1.2) will be awarded by the Connecticut Association of Schools for participants requesting it. For additional information, please contact Jo Ann Freiberg at (860)721-7770 or by e-mail at info@OperationRespectCT.org.

Please submit this form online or, if you prefer, print it out and return the completed form to:

Operation Respect CT
1310 Silas Deane Highway
Suite 217
Wethersfield, CT 06109
Phone: (860) 721-7770
Fax: (860) 529-3281