User Registration

Username/Email

The password must have at least 8 characters, at least 1 number(s), at least 1 lower case letter(s), at least 1 upper case letter(s), at least 1 special character(s) such as *, -, or #

Password

Email Address

Re-enter Email

First Name

Last Name

City/Town

Country

Organization Name

Organizational Role

If you chose "Other" for Organizational Role, please enter your role here.

Job Title (Where you work)

Systems and/or Sector Classification

If you answered "Other" for Systems and/or Sector Classification, please enter here.

How many years have you been active in the field of prevention?

What type of community do you work in?

Zip Code

Race

If you answered "Other" to Race, please enter here.

Are you of Hispanic origin

Please enter your age.

Your Pronouns

If you answered "Other" to Your Pronouns, please enter here

Do you require PDE Act 48 credits?

What is your PPID number?

Please confirm your PPID number.

Do we have permission to release your information to PDE?

Are you here for other continuing education credits?

What CE or CEU credentialing bodies do you report to? List all that apply.

Security question

Required

Work Information

Demographic Information

Credentialing Information