Coordinated School Health Workshop Registration

A completed School Health Index is required for attendance. Indicate the year in which you most recently completed a School Health Index at your School
2008-2009
2009-2010
2010-2011
I would like to complete or update my building’s School Health Index. Please note: assistance is available through the Lorain County General Health District.
Unsure

Payment Information

Make checks payable to ESC of Lorain County. Upon acceptance, please send your team's PO by FAX-Attention Ruth Weible, 440.324.7355, to the Educational Service Center of Lorain County by November 17, 2011. The PO should be made out to the Educational Service Center Of Lorain County, 1885 Lake Ave., Elyria, OH 44035. Prior to the conference your school district will receive an invoice from the Educational Service Center. Registration will include continental breakfast and lunch.

Team Members, including the Contact Person

It is encouraged that teams include a school administrator. To add additional team members to this registration session please choose "Add Another Team Member" following the last drop down menu option. It is recommended that other members of the team include: Board Member, Support Staff, School Nurse, School Counselor, Food Service Director, Elementary or Secondary Teacher, Physical Education Instructor, Health Teacher, Parent, Student or Other Community Member.

Yes, I would like my school health team's contact information to appear on the attendee list which will be distributed at the Conference for networking purposes.

Please contact healthed@loraincountyhealth.com or (440) 322-6367 if you have any difficulties in registering or further questions.

School District:
School Building:
Contact Person:
Work Phone Number:
Cell Phone Number:
Email Address:


	First Last
Name:
Title:
Email Address:
Please indicate any dietary preferences:
I would like to register for:	November 17 - $40.00 February 22 - $40.00 Both: Nov 17 & Feb 22 - $75.00
I plan to apply for graduate credit through Ashland University:
	Yes No
CEU’s and College Credit! Certificates of Participation will be awarded and may be submitted to your LPDC as verification. Participants may earn one graduate workshop credit through Ashland University. The cost for one graduate credit is $278.00 Graduate credit will be granted upon satisfactory completion of all workshop requirements. Attendance is required at both sessions. A representative from Ashland University will be at the workshop, November 17, 2011 to register participants for credit. Payment for credit is due at that time. Students new to Ashland University must bring a photocopy of their teaching certificate, transcript or diploma at the time of registration. Upon receipt of registration, you will receive a confirmation. Ashland Credit participants should plan on meeting at the end of each workshop from 3:00 to 3:30 pm. Questions related to CEU’s/college credit, contact Russell Maruna at (440) 324-5777. ext. 1131.