Weekend ODMRDD Course Registration

All Fields on the form are REQUIRED.

What course are you registering for? [Select one]
Intro to DD Interviewing & Counseling Self-Determination	Habilitation Programming Behavior Supports Group Facilitation/Team Process
Dates of Course:
Location of Course:
Your full name: As It Appears on ODMRDD Certification/Registration
Street Address
City
State & Zip
Home Phone:	(With Area Code)
Work Phone:	(AC & Ext.)
Email address:
County Board/Agency Where Employed:
Job Title:
Type of Credit Needed: College Seminar CEC/CPD
Type of Certification:
Adult Services, Case Management, Service & Support Administration (SSA), Investigative Agent, Early Intervention, Management, Superintendent
Will You Need Lodging Information? Yes No
How did you hear about QEST? (Please check all that apply)	Flyer posted at agency Co-worker/Supervisor Conference I attended Website
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QEST - Quality Enhancement Services & Training

Lesha Self, M.Ed.

Suite 320, 5465 North Bend Road, Cincinnati, OH 45247
P: 513.662.0170 F: 513.662.0939

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