<p> Professional Development for Trainers of Direct Care Workers: Personal Care Skills – Demonstration – Practice – Testing Dementia – What Caregivers and DSPs Need to Know PARTICIPANT REGISTRATION FORM</p><p>Participant Contact Information </p><p>Name Title Company Mailing address City, State, ZIP Code Telephone Fax E-Mail</p><p>Number of years experience as a trainer of direct care workers Number of years experience in direct care field Workshop Selection: which workshop and which presentations/tests will you attend? (Circle/highlight the city of choice, then mark all tests that apply, put an X)</p><p>Choose city: Tucson – Prescott – Yuma – Phoenix – Sierra Vista – Casa Grande – Kingman - Flagstaff Presentations on dementia and skills Written Test: - Fundamentals - Aging and Physical Disabilities - Developmental Disabilities Skills Test: - Fundamentals - Aging and Physical Disabilities - Developmental Disabilities Reply Upon receipt of their registration forms, qualified participants will receive a confirmation letter and information about times and location. A light lunch will be provided at the workshop. Feel free to bring your own snacks. Please check if you would like a vegetarian lunch: ______To reserve a seat, return this form to Jutta Ulrich at [email protected] 1) Fax this Registration Form to: Jutta Ulrich FAX 602-542-6575 2) Mail: Jutta Ulrich, DES – DAAS SC 950A, 1789 W. Jefferson, Phoenix AZ 85007 3) E-Mail: You can fill this form in “Word” and e-mail it to [email protected]. To get an electronic copy, download it at www.azdirectcare.org (“For Trainers”)</p>