Registration      New York State Department of Health    Long Term Care Restructuring Initiative Collaborative Sessions   

Date & Time	Location:	Registration Deadline:	
Agencies that have access to the STARS system are encouraged to use STARS for their registration needs.

All others should FAX this form to Registration Services (716)-796-2202
	
Wednesday May 31, 2006

10:00 AM - 03:00 PM
	Uniondale Marriott
101 James Doolittle Boulevard
Uniondale, NY 11553	Wednesday May 17, 2006		

County: ___________________________  Agency: _____________________________________________________________________  Phone: (        ) _____________________ 
Address: ______________________________________________________  City: _________________________________  State: NY     Zipcode+4_________________________
Contact Person: ___________________________________________  Title: __________________________________________________  Fax: (        ) ______________________
Contact Person’s E-mail address: ______________________________________________________________________________________________________________________

Application Codes	

Applicant Name
(Please print or type in order of priority)
First Name    Last Name

Email
Address	

Social
Security Number
(Last 4)

Job Title	Job Type	Functional Area		
1.								
2.								
3.								
4.								
5.								

Specify needs of any handicapped applicant:  ____________________________________________________________________________________________________________

1.	Administrative			11. Indian Affair Services		21. Homeless Services
2.	OCFS Rehabilitative Srvc	12. Adult Services			22. Fraud & Abuse
3.	Adoption			13. Services/Other			23. Medicaid Skills
4.	Child Protective Services	14. Legal Affairs/Counsel		24. Medicaid Eligibility
5.	Day Care			15. Energy Program		25. Managed Care
6.	Domestic Violence Prev		16. Food Stamps			26. Dept of Health/Other
7.	Foster Care			17. Temporary Assistance		27. Welfare To Work
8.	Residential Child Care		18. Child Support Enforce		28. Dept of Labor/Other
9.	Blind & Visually Handicap	19. Disability Determinations		29 F-30 Non Admin/Local
10.	Prev/Family Support Srvc	20. Transitional Services

1.	Administrator	11. Health Care
2.	Supervisor/Manager	12. Teacher Vocational Specialist
3.	Clerical/Support Staff	13. Professional (Policy, Prog. Dev)
4.	Consultant	14. Recreation Specialist
5.	Caseworker/Case Mgr/Social Work
6.	Direct Child Care Worker
7.	Eligibility Worker
8.	Foster/Adoptive Parent
9.	Investigator
10.	Volunteer Worker

Functional Area Codes

Job Type Codes

Training ID:
58794

Center for Development of Human Services ● Buffalo State College SUNY ● 1695 Elmwood Avenue ● Buffalo, NY 14207-2407 Tel: (716) 876-7600 ● Fax: (716) 796-2202