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TEENS IN ACTION TRAINING REGISTRATION
11 AM - 5PM: April 12th - 13th
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7000 Franklin Blvd, Suite 210, Sacramento, CA 95823
Location of Training - We Can Work It Out INC.
Both (2) Sessions are required to complete certification.
First Name
*
Your answer
Last Name
*
Your answer
Email
*
Your answer
Phone Number
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Your answer
If needed, can we reach you by text using the above number?
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Yes
No
Name of your organization, group or school. (Skip if not applicable)
Your answer
Address of Organization, School, or Group Affiliation
Your answer
Personal Address (for certification purposes only)
*
Your answer
Continuing Education Hours
Would you like to receive free Continuing Education Hours?
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MFT and /or LCSW's - California Board of Behavioral Sciences
CCAPP - California Consortium of Addiction Program and Professionals
No, I am not interested or licensed by BBS or CCAPP
If yes, please provide license #
Your answer
The following demographic questions are for reports and funding purposes.
If you are registering with Mentor or a Teen(s), please provide name of Mentor or Teen(s).
*
Your answer
AGE
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12 - 14 ....... *Must Have Adult Mentor Register
15 - 17 ....... *Must Have Adult Mentor Register
18-20
21-24
25-44
45-64
65 and over
Prefer not to answer
Ethnicity:
*
Hispanic/Latino
White
Black/African American
Native Hawaiian/ Other to Native Hawaiian / Other Pacific Islander
Asian
American Indian/Alaska Native
More than one ethnicity
Prefer not to answer
Sex
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Male
Female
Other
Prefer not to answer
By checking the boxes below, I agree to the following:
*
ATTEND Both (2) training sessions to complete certification.
Lead the program in Sacramento County with 10 Teen participants to receive the $200 Gift card.
Required
Thank you for your registration. Our Outreach Coordinator, Chris Serra, will contact you within 5 business days to finalize your registration. If you have any questions of concerns please you may contact Chris by Phone or Email. 916.662.2739 or
chris@omniyouth.net
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