Test Prep Registration Form

TEST PREP REGISTRATION Form

P.O. Box 80235 Baton Rouge, Louisiana 70898-0235 | www.LASACT.org
TEST PREP REGISTRATION
GENERAL INFORMATION:

Complete the form below to register for the Test Prep Workshop held in Baton Rouge.

6 CEUS!

WHERE: Our Lady of the Lake Hospital

5000 Hennessey Blvd.

Baton Rouge, LA 70808

DRIVING DIRECTIONS:

The instructor will be James Truax, LAC, AADC, CCDP-D The class will be held at Our Lady of the Lake Hospital, 5000 Hennessy Blvd., Baton Rouge LA 70808. The follow are the directions to the hospital and the number at the bottom of the page is my cell number if you need more assistance. Looking forward to seeing all of you.

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If traveling north on I-10 take the Essen Lane exit.

Turn left onto Essen and go to Hennessy Blvd the third Red-light. Turn right and park in second parking lot across the street. Enter the main hospital entrance across the street. You will see the gift shop on your right; I will meet you there at 8:45 a.m. I will take you to the conference room.

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If traveling south on I-10 take the Essen Lane exit.

Turn right onto Essen and go to Hennessy Blvd the third Red-light. Turn right and park in second parking lot across the street. Enter the main hospital entrance across the street. You will see the gift shop on your right; I will meet you there at 8:45 a.m. I will take you to the conference room.

James Truax: 225-287-3573.
Applicant Information
Test Preparation Workshop Date
Name

Last NameFirst Name/M.I.
Preferred Pronouns
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address (Required)
example@example.com
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Position Title
Employer Mailing Address: Type N/A in the fields if you do not have any of what's listed below

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you a LASACT Member?
Credential Information

Type N/A in the first box if you do not have any of the credentials in either table below.

ADRA Credentials

Rows	Type LAC	CAC	RAC	CIT	LPP	CPP	RPP	PSIT	CCS	CCGC	ATA
No.
Exp. Date

LASACT Certificates/Other Credentials

Rows	Type AADC	CCJP	CCDP	CCDP-D	PRSS	LPC	LMFT	LCSW	LMSW	SAP	OTHER
No.
Exp. Date

Payment Information
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Test Prep Workshop - MEMBER
$79 Test Prep Workshop fee + $4 transaction fee for all credit/debit card payments

$83.00

Test Prep Workshop - NON MEMBER
$99 Test Prep Workshop + $4 transaction fee for all credit/debit card payments

$103.00

Total

$0.00
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TEST PREP REGISTRATION Form

TEST PREP REGISTRATION

Applicant Information

Credential Information

Payment Information

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