Check preference and also indicate second choice of training dates.   

Please indicate if you wish to attend the Smart Moves daylong session the day before Retraining or the Special Population daylong session  following your Retraining week (subject to availability.)

        NAME________________________________________________     Daytime Phone #(_____)-_____-________   

        Mailing Address__________________________________________    Evening Phone#(_____)-_____-________

        City _____________________________________, State__________ Zip Code______________  

         email _____________________________________________________       M____    F____  

Are you teaching now?                 How many classes?                      What level of class?                      
Is this your first retraining?                 Where are you teaching?_______________________________

Successfully completing the retraining will renew your certification for three years.  At least one retraining is required before qualifying for a short retraining or the next level of certification.  Though you may repeat retrainings as many time as you wish, we encourage you to explore the other options for more advanced certification described in the Certification Handbook

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LOCAL ARRANGEMENTS:
Double or single occupancy*____________ Roommate_______________________

Date of arrival ____________________Approximate time_________________

     Traveling by car_____   bus_____   air _____ ?

Need for shuttle service from Lexington Airport ($35.00 round trip)?__________

          Arrival time____________Airlines and Flight #__________________

          Departure time__________Airlines and Flight #__________________

*The workshop fee for 5 nights and 5 days is based on double-occupancy unless you indicate otherwise.  Single-occupancy carries an additional charge of $100 for 5 nights.  **The workshop fee for either the Smart Moves

training or Special Populations training is an additional $100. 

·         Application Deadline: 1 month before the retaining.  Please contact this office if the deadline has passed.

·         A non-refundable deposit of $100 must accompany this application.  The balance ($400) will be due on or before registration.