2. 
4. LCT Members: Please complete ONLY the top half of the form
6. First Name*
7. Last Name*
9. Place of Employment/Organization *
11. Position Title*
12. Degree and Licensure *
13. CEU approval*

    1. Yes
    2. No
15. Work Address*
17. City*
18. State
19. Zip
21. E-mail*
22. Phone number
24. Dietary Restrictions

    1. Yes
    2. No
25. If yes, please describe:
27. LCT guest attendees, please complete ONLY the fields below
29. First and Last Name (LCT guest attendee)
31. Place of Employment/Organization
33. Position Title
34. Degree and Licensure
35. CEU approval*

    1. Yes
    2. No
37. E-mail
39. Dietary restrictions

    1. Yes
    2. No
40. If yes, please describe:
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field