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Online Registration for STAR:

  • Level I
  • Youth

Participant Information

Family name (surname)***
First name***
Middle or initial
Name you prefer to be called
Organization
Position

Mailing Address


Street or Post Office Box***
City***
State or province***
Postal code*** [look up U.S. or Canadian codes]
Country***

Phone/FAX/Email

(Please include area code, country and city codes with the phone numbers.)

Home phone
Office phone
Cell phone
Fax
E-mail address #1
E-mail address #2

Personal Information

Which of the following best describes you occupation/role:
Gender*** Female Male
Religious affiliation
Denomination
How did you hear about STAR?*** From a web site.
      Which?
Friend or colleague.
      Who?
Email
Presentation.
      Which?
Newsletter or bulletin.
      Which?
Newspaper or magazine.
      Which?
Brochure
Do you want 2 CEU credits from EMU for the seminar? ($25.00) Yes No
I am licensed in a counseling profession. I would like to recieve 1 CE (from the NBCC) for every session hour I attend. ($10.00) Yes No
CEs: One CE for every hour of seminar attended is awarded to professionals seeking CE Hours for licensure requirements. Registrants may request CE Hours on the registration form or by calling 540-432-4651. The EMU MA in Counseling Program will issue the CE Hours certificates through the National Board for Certified Counselors (NBCC), provider #4488. The total cost of CEs from NBCC is $10.

For non-US participants

To facilitate the processing of your registration form, this section must be filled out correctly, please be sure to provide your name as it is printed on your passport.
Name exactly as on passport
Country of citizenship
Country of birth
Passport number
Do you current hold a US visa? N/A Yes No

Seminars Dates

Please indicate your first, second, and third choices for the seminar you would like to attend.

October 27-31, 2008 — Level 1
February 16-20, 2009 — Level I
March 23-29, 2009 — Level II
June 8-12, 2009 — Level I
September 14-18, 2009 — Level 1
The cost for Level 1 and Youth STAR is $560.00.

I or my organization will pay the applicable course/mini-workshop fee.

I would like to apply for a partial scholarship (towards the training fee only); please send me a scholarship application form. (Your application must be received by the Scholarship Application Deadline indicated on your Scholarship Application Form.)

SUPPLEMENTAL INFORMATION

  1. Statement of Experience.

    Please briefly describe the relevant training, work and personal experiences that motivate you to attend the STAR program.

  2. Statement of Intent.

    Please briefly describe your objectives for attending the STAR program and the ways in which you expect to apply the training you receive.