Drug and Alcohol Treatment Association of Rhode Island
JULY 2006 - JUNE 2007 Registration Form
To be completed and mailed with $40 annual registration fee

Name: __________________________________  

Address:  _______________________________


Last 4 digits of your SS#:__________

Agency: _______________________

Home Tel: ______________________

Work Tel: ______________________

Emai: _________________________
The following information is requested in order to comply with grant funding requirements:

Sex
___ Male
___  Female

 Race/Ethnic Origin
____African American
 ____ Native American Indian
____ Asian/Pacific Islander


____ Latino/Hispanic
_____Caucasian
_____Other
Your primary profession (check one only):

_____Counselor/Clinician
_____ Employee Assistance
_____ Clinical Director/Supervisor
_____ Criminal Justice
_____ Stud. Assist Counselors

_____Health/Medical
_____ Clergy
_____ Outreach/Follow-up
_____ Prevention
_____ Task Force Member

_____Program Director/Admin
_____ Non Drug/Alcohol Prof.
receiving cross training

_____ Other
Current Certifications or Licenses (check all that apply):

_____ Chemical Dependence _____ProfessionalPrevention Specialist

_____Social Work
_____ Nursing

_____Mental Health Counselor
_____ Other: __________
Special Accommodations: Wheelchair accessible space and sign language interpreters are available.
Please note your accommodation requests here: __________________________________

Your $40 registration fee applies toward the training year
July 2006 - June 2007.

Make check payable to: 
DATA of RI
Mail payment & application forms:
DATA
Attn: Linda Caparco
102 Dupont Dr.,
Providence, RI 02907

FOR OFFICE USE ONLY
Check # __________ A ________P
Amt Recv'd $_____________ __

Date Recv'd _____________
Registration ____Course Fee