Participant #1

Participant #2

LAST NAME

FIRST NAME

MIDDLE INITIAL

LAST NAME

FIRST NAME

MIDDLE INITIAL

PHYSICAL ADDRESS (NUMBER)

STREET MAILING ADDRESS (IF DIFFERENT)

CITY

COUNTY

STATE

ZIP CODE

DAYTIME PHONE

( ) -

HOME PHONE

( ) -

E-MAIL ADDRESS

FEE: PLEASE CHECK applicable box below:

Married couples must attend together, if both need the training.

Single applicants- (are welcome to bring 1 adult significant other)

*Free to those who already have a Wisconsin foster/relative child in their home placed by a County DHS or Special Needs Adoption Agency.

*Free to those who do not have a child in the home, but have submitted an Application to the Special Needs Program.

$300.00 fee applies to all other families. If you do not fit in to the above two categories, you are welcome to attend, but at your cost. Fees may be recouped after finalization of an adoption. Ask your Social Worker for details if you are not aware of one-time reimbursable expenses.

Please include a check with registration form, payable to "Lutheran Social Services" with "293 Training" written in the memo line

or provide credit card information:

Credit card #: _ _ _ _ - _ _ _ _ - _ _ _ _ - _ _ _ _ Expiration Date: _ _ - _ _

7 digits on back of card by signature: _ _ _ _ _ _ _

________________________________________________________________________ ________________________

Cardholder Signature Date

RETURN FORM TO:

CHERYL JONES – This e-mail address is being protected from spambots. You need JavaScript enabled to view it

LUTHERAN SOCIAL SERVICES

1320 W. Clairemont Ave., STE. 100

EAU CLAIRE, WI 54701

TOLL-FREE: 888-746-2850 or 715-456-5663

IF WORKING WITH AN AGENCY/SOCIAL WORKER, PLEASE INDICATE:

Agency:_____________________________

Social Worker:________________________