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5. Mailing Street Address
6. Mailing Address - City
7. Mailing Address - State
8. Mailing Address - Zip Code
9. Cell Phone
10. Time Zone
11. Check the group(s) that you currently belong to: 1.) ALLIANCE MEMBER - is specifically for those individuals NOT in Michigan - that are part of the Alliance for the Advancement of Infant Mental Health 2.) DWIHN - If you work at one of the IECMH organizations within "Detroit Wayne Integrated Health Network", check BOTH DWIHN AND either Non-Member or MI-AIMH Member 3.) MI-AIMH MEMBER - Select if you are a current MI-AIMH Member 4.) NON-MEMBER - Check if you are NOT a MI-AIMH Member 5.)STUDENT - Current students will be required to email a copy of their current student ID or class schedule to lsheldon@mi-aimh.org
12. 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
13. Agency/Organization
14. Please indicate your discipline
15. Please indicate your primary practice setting.
16. How many years have you been working on behalf of infants, young children and families?
17. Check the continuing education credit type(s) you will need for your professional development.
18. 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: MDE-EducatorHelp@michigan.gov
19. 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.
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