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Mailing Street Address *

Cell Phone *

Agency/Organization *

If you checked that you require continuing education credits on the previous question, your license # is required to receive CEC's. Enter your license #. Enter it like this: Social Work #6801000 or LPC# 410000 If you require SCECH's your Personal Identification Code (PIC#) is required - enter it below. NOTE: You must include your PIC number exactly as it appears in your MOECS account. If you do not know your PIC number, please email MOECS for their assistance: [email protected]

Enter either your MI-AIMH Member ID or your Alliance State/Country if you checked YES to MI-AIMH Member or Alliance Member on the previous question

City *

Zip Code *

Are you a professional who needs their attendance verified on: https://www.miregistry.org/ such as Early Childhood Educators, Center Based Directors etc. for your work? If so, please add your MiRegistry Number below so we can add your attendance to your training log. MiRegistry.org is not hosted by or affiliated with MI-AIMH, and you do NOT need to have a MiRegistry profile in order to participate in the MI-AIMH Conference. This is optional and only for those required to have their trainings in miregistry.org for their work.

2-Letter State Code. Example: Use MI for Michigan. *

Please indicate your discipline *

Please indicate your primary practice setting. *

How many years have you been working on behalf of infants, young children and families? *

Check the continuing education credit type(s) you will need for your professional development. *

Social Work

Professional Counselor

IMH or EC Endorsement®

State Continuing Education Clock Hours (SCECH): as a certified teacher/school administrator (elementary and secondary)

Not applicable at this time

group_preference *

Community Member: A general participant not tied to a specific role or membership. Detroit Wayne Integrated Health Network (DWIHN)-If you work at one of the IECMH organizations within DWIHN, check BOTH DWIHN AND either Non-Member or MI-AIMH Member Member with The Alliance for the Advancement of IMH (those outside of Michigan) MI-AIMH Member (has a paid membership with MI-AIMH) Non-Member (Professionals who do not have a paid MI-AIMH Membership) Student (Current students are required to email current student ID or class schedule to [email protected])