Child Abuse Prevention Summit

May 14, 2008

Marriott Courtyard, 3301 Lemone Industrial Boulevard, Columbia, MO

Co-sponsors: Mercy Health Plans & Fraternal Order of Eagles of Columbia, MO

Register by May 9, 2008

Cost: $10 per person

Registrant Information

Please fill out your contact information below.

*First Name:

*Last Name:

Title:

Organization:

*Address:

*City:

*State:

*Zip:

*Email:

*Phone:

Your Specific Job Roles

Agency Mission:

Agency Services/Programs

Community Partnerships/Collaboratives Addressing Child Abuse Prevention

Are you or others in your agency engaged in community or regional collaboratives, networks, councils, partnerships or consortia with a primary focus on child abuse prevention?
Yes
No

If yes, please name the collaboratives/partnerships/network:

Are your or thers in your agency engaged in community or regional collaboratives, networks, councils, partnerships or consortia that address child abuse prevention as part of a larger mission?
Yes
No

If yes, please name the collaboratives/partnerships/networks:

Prevent Child Abuse America & Missouri Organizations

Are you familiar with the work and mission of Prevention Child Abuse America?
Yes
No

Did you have experience working with the prior Prevent Child Abuse Missouri organization?
Yes
No

Please share experience that you think would be helpful to Missouri KidsFirst:

Areas of Expertise or Interest

Technical Assistance Needs

Registration

Registration Fee: $10 per person

Registration Deadline: May 9, 2008

Make Check Payable To: Missouri KidsFirst

Please Return Check and Registration Form To: Missouri KidsFirst, 312 Monroe Street, Jefferson City, MO 65101

*Payment Option:
Pay with check (please print the registration form and return with the registration fee before hitting the submit button)
Pay with credit/debit card using Paypal (there will be a $1 processing fee)
Pay with credit/debit card by fax (please print the registration form before hitting the submit button and fax to 573/632-4601)