Event Registration

June 2024 Life Space Crisis Intervention Certification

Jun. 17, 2024 - Jun. 21, 2024
7:30 AM
Des Moines Area

Instructions: Please complete the following form. If you are paying by credit card please ensure that the address you provide matches your credit card billing address. If you use a check, your confirmation page will provide you with information on where to send the check.


Items with a * are required.

First Name *  
Last Name *  
Position/Title *  
Secondary Position/Title  
School/District/Institution *  
Billing Address 1 *  
Billing Address 2  
Billing City *  
Billing State *  
Billing ZIP code *  
Geographic Location by AEA *  
Email *  
You will use this password for future registrations.
Password  
Confirm Password  
Work Phone  
Home Phone  
Cell Phone  
Gender *  
Age Group *  
Ethnicity  
How did you hear about us?  

Choose your organizational classification: *
Event Participant ($1000.00)  
Non Member ($0)  
Non Member - Student ($0)  

Please select the desired payment type: *
Credit Card 
Check 
Bill Me / P.O.   



For more information please contact Iowa tech@iowaascd.org

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