Only Complete, Typed Applications Will Be Accepted

2018SUMMER SCHOOL OF ADDICTION STUDIES

Personal Information
Last Name / First Name / M.I.
Address
City / State / Zip Code
Home Phone / Cell Phone
E-mail (required)
T-Shirt Size (Default = L) / S M L XL XXL Other______
Have you previously attended the school? / ☐Yes ☐No / If yes, list the year(s)
How did you hear about SSAS? / ☐Online ☐ Mailer ☐Colleague ☐Other______
Education Information
Degree / School / Grad Year
Employment Information
Employer / Position
☐ Full Time ☐ Part Time
Professional Licenses
Do you hold any professional licenses or certifications? / ☐ Yes ☐ No
If yes, please list along with your license number(s)
Registration -- We strongly recommend online registration!
Pleaseprovide your morning and afternoon course choices; all efforts will be made to ensure your choosing, however class seating is limited and courses will be filled on a first-come, first-served basis.
Session / Please write the course code and course title:
(1)Morning Session 9:00 a.m. – 12:00 p.m.
(2)Afternoon Session 1:15 p.m. – 4:15 p.m.
Registration
SSAS Tuition
Registration includes FOCUS DAY 18 programming, two 3-day courses, three ‘lunch & learn’ events, and three afternoon lectures. [CE hours: ~35] Lunch will be served each day. A professional networking picnic dinner is included on Sunday night. Parking is free for all registrants.
By May 1st: $575 | After May 1: $750
“Pizza and a Movie – 2 CE Hours” with Dr. Anthony Tobia
We are hosting a 2 CE hours “Dinner and A Movie” event on Tuesday night (6 – 8 pm).
Pizza and Movie: $20
Focus DAY 18 Only: Includes 5 CE hours.
1-day registration: $75 | After May 1: $175
Binder
In an effort to be eco-friendlier, we will have all documents available on our App – Whova, which you can download for free. Alternatively, if you would like a binder with copies of all materials, there is a $25.00 fee.
Accommodations
I request the following accommodations:
☐ Wheelchair Accessibility
☐ Other / Dietary preferences/restrictions:
☐ Vegetarian
☐ Other
Payment Information *All Summer School applications must include a payment* / Amount: $______* ($575 by 5/1/17; $750 after 5/1/17)
☐ / Summer School 2018 / Amount: $
☐ / Pizza and a Movie (Optional) / Amount: $20.00
☐ / FOCUS DAY 18 Only / Amount: $
☐ / BINDER (Optional) / Amount: $25.00
☐Enclosed is my check for $______drawn on a US bank, made payable to Rutgers, The State University of NJ
☐Please charge my MasterCard/Visa account for the amount of $______
☐I am paying with a purchase order (PO#______)
Cardholder’s Name
Card Number
CVV (# on the back / ExpDate
Signature / Zip Code

* Military personnel and Rutgers students and employeesmay qualify for reduced tuition. Contact us for qualifications.

Only complete, typed applications will be accepted.

MAIL: Addiction Education, Center of Alcohol Studies, 607 Allison Road, Piscataway, NJ 08854

FAX: 732-445-3500 REGISTER ONLINE: alcoholstudies.rutgers.edu/ssas