WORKSHOP REGISTRATION FORM

LIMITED ENROLLMENT

Register by October 15, 2001 and receive a discount. (payment must be received by
10/15/01 to receive discount).

Final registration deadline: November 8, 2001 (Payment must be received by 
11/08/01 to be registered).

Please Note: You may only sign up for one event.

***Lunch and snacks will be provided***
Professional Fees:

Sign up for either:               Before 10/15       After 10/15    Contact Hrs

/_/  Basic CISM Course          $120.00                  $135.00          14

/_/  Advanced CISD Workshop  $75.00                   $85.00             7

Student fees: Note: Must provide Proof of full-time student status

Sign up for either:           Before 10/15             Before 11/8     Contact Hrs.

/_/  Basic CISM Course            $90.00                   $100.00         14

/_/  Advanced CISD Workshop  $40.00                    $50.00            7


__________________________________________________________________________
Name
__________________________________________________________________________
Organization                                                                                 Phone
__________________________________________________________________________
Address
__________________________________________________________________________

Method of Payment:    /_/  Check   /_/  Money Order   /_/  IDR (UW Departments only)
Make checks payable to:  "University of Wyoming Counseling Center"

Please mail or fax this form to the address listed below. Phone registration 
is also available, however, payment must be received by the deadline to 
confirm registration.

Discount rates are available at the Laramie Holiday Inn for those wishing
to stay overnight. Register by 10/15 & use code "CIS".  Phone: (307) 742-6611

For further information, please contact:      

 George Steffian, PhD                               Phone: (307) 766-2187
 University Counseling Center                        Fax:  (307) 766-3412
 340 Knight Hall                         Email:       georges@uwyo.edu
 P.O. Box 3708
 Laramie, WY 82071-3708                       OR                                                
                                              George W. Doherty                                   
                                              Rocky Mountain Region Disaster   
                                              Mental Health Institute                Pager: (307) 745-1372
                                              Box 786                        Email:         GeorgeDoherty@callatherapist.com          
                                              Laramie, WY 82073-0786            
                                                          


Presenter Information

Basic Critical Incident Stress Management Workshop

Advanced Issues In Critical Incident Stress Debriefing Workshop