<% if (Request.ServerVariables("REQUEST_METHOD") = "POST") then Dim item, val, sTo 'sTo = "jkilian@alliance1.org" sTo = "wwwordercm@feinet.com" Init 1 Readtemplate "registration.inc" For Each item in Request.Form val = Cstr(Request.Form(item)) Parameter item, val Next SendMessage _ "FormProcessor@feinet.com", _ "", _ sTo, _ "FEI Behavioral Health", _ "FEI-Responder Training Registration" Response.redirect "confirm.asp" end if Function FilePath(strPathAndFile) For intLCV = 1 to Len(strPathAndFile) If Left(Right(strPathAndFile,intLCV),1) = "/" Then intCutPlace = Len(strPathAndFile) - intLCV + 1 Exit For End If Next FilePath = Left(strPathAndFile,intCutPlace) End Function %> FEI-Responder.com -- Registration

FEI Responder Network - Registration Form (updated 11/21/2008)

<<Applications are due no later than two weeks prior to the scheduled training dates>>

 

FEI Requires a graduate degree in a behavioral science, a license to practice in your state and malpractice insurance that covers 1Million/3Million.

Please see the FAQ Page for more information on approved training and/or experience. Please click here for a description of FEI Responder Roles.

Please do not contact the training host sites directly with questions about training program content, prerequisites, or scheduling. Please direct questions or concerns to cm@feinet.com .

Please provide the following registration information:

 

Training Date:

 

Demographic Information:

 

First Name: Last Name: Middle:

 

Organization/Agency Information:

 

Address: 

 

City:  State/Province: Zip/Postal Code: 

 

Personal/Home Information:

 

Address: 

 

City:  State/Province: Zip/Postal Code: 

 

Contact Information:  Phone Numbers are used to contact you for deployment.  Please use contact information that are for emergencies: (agency phone numbers are not used)

 

Agency/Office Phone: Home Phone:
Mobile Phone: Pager/Alternative:
Fax: Email:

 

FEI Requires a graduate degree in a behavioral science, a license to practice in your state and malpractice insurance that covers 1Million/3Million. Please affirm you meet these qualifications.

 

Master Degree (OR) Doctorate  State License Malpractice 1M/3M

 

Years of Post Graduate Experience:

 

Although not required, please specify any special certification or experience you have in the area of critical incident debriefing, trauma, grief, disaster response or crisis management:

 

 

Travel Questions:

 

Name and Location of Nearest Airport:  eg. General Mitchell International Airport - MKE - Milwaukee, WI

Other Airports within 100 miles: 

 

Do you have a Valid Passport?   if yes, please specify:

 

Passport #: Expiration: 

 

How did you learn about these training programs?

 

Mailing Colleague Fax Website Email Other (please specify) 

 

 

Please note that in addition to the above information, we will also also need a copy of your resume, and if applicable a copy of your state license/certificate, previous training certificate(s) and proof of professional liability insurance with limits of $1 million per occurrence and $3 million per aggregate.  Although these are not required at the time of training registration, it is helpful to both you and FEI to send these materials at your earliest convenience to: (FAX/email/US Mail)

 

FEI Behavioral Health

Network Operations

11700 West Lake Park Drive

Milwaukee, WI 53224

Fax:  (414) 359-1973

cm@feient.com