IMPACT Leader Certification

Date:

April 12-15, 2011

Location:

Floyd County DFCS

450 Riverside Parkway

Suite 110

Rome, GA 30162-0193


Registration: Must be e-mailed to . Space is limited to 20 participants per class. There will be no provision for on-site registration or payment. DFCS supervisors should use the new online registration system to register DFCS staff, foster parents, and contractors for this class. Private agencies (including individuals who plan to contract with DFCS in the future) should use the attached form to register for this class.

Fee: Private agency registration fee is $175. All fees are due before the training. ***All checks and money orders should be made payable to HROD/DHR.*** Please ensure that the name of the registrant is written on the check or money order. Please forward your payment to:

DaJaneshia Jones

Re: IMPACT Leader Certification

DFCS Education and Training Services

2 Peachtree Street, NW Ste 26-267

Atlanta, GA 30303-3142

Confirmation Letters: Confirmation letters will be generated by the computer once your Registration form and fee have been received.

Cancellation Policy: If you are unable to attend the training, please e-mail our registration office at


Division of Family and Children Services

IMPACT Leader Certification

April 12-15, 2011

DEADLINE: April 5, 2011

REGISTRATION FORM

(Please print clearly and completely)

Name (F, MI, L):
Social Security No.
Title:
Supervisor / Name of Supervisor / Phone:
Organization:
Address:
City, State, Zip:
Phone: / Fax:
E-mail: (PLEASE INCLUDE)

Does your agency need an IMPACT Pre-Service Training Video? Yes or No

Registration: Must be e-mailed to . Space is limited to 20 participants per class. There will be no provision for on-site registration or payment.

Fee: Private agency registration fee is $175. ***All checks and money orders should be made payable to HROD/DHR.*** Please ensure that the name of the registrant is written on the check or money order. Please forward your payment to:

DaJaneshia Jones

Re: IMPACT Leader Certification

DFCS Education and Training Services

2 Peachtree Street, NW Ste 26-267

Atlanta, GA 30303-3142

Confirmation Letters: Confirmation letters will be generated by the computer once your registration form and fee have been processed

Cancellation Policy: If you are unable to attend the training, please e-mail our registration office at .

Revised 100/14/08