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PRIM~E Registration Form : 2009-2010

Note:   Print this entire form. All 3 parts of this form must be filled out in ink and mailed with a deposit or payment (check or credit card) to the office listed below for the Registration to be accepted.  NOTE: You are not registered until the registration is confirmed.

PART 1

First Name_____________________ Last  Name_________________________

S.S. #_______________________  Degree ______  Specialty_____________________

Phone # (day) ______________________ (evening) _______________________

(Fax)______________________ (E-mail) _____________________________

Mailing Address (H) (B)  ______________________________________________

City_________________________    State________    Zip  Code _______________  

How did you find out about PRIM-E...?

_____ Mandated by licensing board or other credentialing agency  

_____ Suggested by licensing board or other credentialing agency

_____ Other (Please explain) _______________________________________________________

Licensing Board or Referring Agency: _________________________________________________

Name of Contact Person: ____________________________________________________________

Address__________________________________________________________

City _________________________   State _______    Zip Code_______________

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PART 2

I wish to register for the following session: ______________________________________

Please call (973) 972-4267 (or 1-800-227-4852) to check course availability. Attendance is limited and courses fill up quickly. Registration MUST be done by mail and is not complete until the registrant receives confirmation of the registration.

Course Dates:	Course Status:	Registration Deadline:
August 21-23, 2009	Course Concluded
October 2-4, 2009	Registration Full - Course Closed
February 5-7, 2010	Course Open for Advance Registration	January 22, 2010
March 26-28, 2010	Course Open for Advance Registration	March 12, 2010
Other courses will be added for	Spring, Summer and Fall

Note: If the course you would like to attend is closed, please call (973) 972-4267 or 1-800-227-4852 to see if another course is scheduled. A minimum registration number is required but additional courses may be scheduled.

_____ Check Enclosed payable to:  UMDNJ-CCOE 

_____MasterCard        _____Visa        _____American Express 

Card #__________________________________Exp. Date_________________ 

Amount $___________Card Holder Signature____________________________

Mail to: UMDNJ-Continuing Education,  

P.O. Box 1709, Newark, NJ 07101-1709    

If you are physically challenged and wish to discuss provisions that make your learning environment more effective, please contact Ms. Attasha Nurse at (732) 235-7430.

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PART 3

Dates/Location   The PRIM~E... Program is scheduled to be offered at the Hilton Garden Inn, 500 Promenade Boulevard, Bridgewater, New Jersey. A block of rooms has been reserved at a special rate of $99 which includes a full American breakfast. The facility includes an indoor pool, whirlpool and fitness center.   The hotel is quite new and is very nicely furnished. All rooms have a small refrigerator (no mini-bar); there are built-in hair dryers in each bathroom.   For hotel reservations call the hotel directly at (732) 271-9030 and mention that you are with the UMDNJ group. This will guarantee that you get our negotiated corporate rate and the included full American breakfast. The dress code for the weekend is casual, comfortable. The atmosphere is friendly and non-judgemental.

Required Readings   Required readings are provided well in advance of the course and two simple written assignments must be completed in advance and brought to the first session. A third written assignment must be completed at the end of the course. Details for these assignments will be provided after your registration is received.

Terms and Conditions   Tuition for the PRIM~E... course is $1,200 which must be paid in full two weeks before the start of the sessions. A deposit of $300 is required with this enrollment form. This represents a non-refundable administrative cost of $50 and a reservation deposit of $250. The deposit will be refunded if you cancel no later than two weeks before the start of the course. No refunds will be made for cancellations received later than two weeks before the start of the course.

The tuition includes all teaching and reading materials plus coffee breaks and lunch on Saturday. Travel, hotel and meal expenses for the two-night weekend session are the responsibility of the participant. Those that live in proximity to the hotel are welcome to commute.

Upon enrollment in the PRIM~E... program, it is understood that:     

1. If the enrollee has entered into a consent agreement or adjudication order with the licensing board, signing this form will constitute permission for the Director of the course to request a copy of that consent agreement or adjudication order from the appropriate licensing board; Signing this form also gives permission for the Director of the course to provide an assessment of the enrollee's participation in the course to the referring licensing board or agency;   

2. Participants must attend all sessions, participate in the discussions, and complete all written assignments in order for the faculty to provide an assessment to the appropriate licensing board.   

3. This assessment will include: (a) certification of participation; (b) a copy of the final written assignment with faculty commentary; (c) an overall opinion of the participants capacities for ethical reasoning and insight demonstrated during the entire PRIM~E... course.  

4. This assessment of the participants work in PRIM-E... will contribute to   the information reviewed by the licensing board and may be a necessary--but is not a sufficient--condition for resolving the participants dispute with the board.

I understand these terms and conditions of the PRIM~E... program and hereby agree to abide by them and provide authorization for the faculty to assess my participation and to divulge the assessment to the licensing board that has jurisdiction.

Signed: _________________________________________Date:_________________

All 3 parts of this Registration Form must be completed in order for registration to be accepted. Mail the completed form and your deposit/payment check (made out to UMDNJ-CCOE) to:

PRIM~E Course Registrar
UMDNJ-Continuing Education
P.O.  Box 1709
Newark, NJ 07101-1709