HIV/AIDS/HepC Prevention for Recovery Coaches Registration
Please complete this form to be considered for enrollment in HIV/AIDS/HepC Prevention for Recovery Coaches Registration being held Tuesday, May 18th, 2021 from 8:30am - 4:00pm.

Space is limited to 30 people. Completion of this form does not ensure registration. You will get either a confirmation email that you have been enrolled, or an email stating you are on the wait list.

Any questions please contact Lauren Chambers lauren.e.chambers@hitchcock.org 
Sign in to Google to save your progress. Learn more
First and Last Name (as you want it printed on certificate)
Email Address
Phone Number (in case we need to contact you the week of the training)
Mailing Address (where you can receive mailed manuals)
Are you affiliated with an organization or agency?
Are you interested in pursuing recovery coaching (and/or CRSW) as a career/profession?
Clear selection
Do you require any assistive accommodations for this virtual training? (i.e., closed captioning, assistance for deaf/hard of hearing, etc.) Please specify and we will do our best to accommodate
PLEASE NOTE: due to extensive wait lists for our free trainings, do you agree to notify event organizers if you need to cancel your registration at least 10 days prior to event start date? A "no show" with failure to cancel will affect your ability to register for future free trainings. Please type "I agree" below
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy