*Name:
Organization:
*Mailing Address:
*City:		*State:		*Zip:
*Day Phone:	Fax:
*E-mail:

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Below is the list of training dates. Please note that these dates are subject to change, so please verify times and dates beforehand.

You may sign up for more than one type of training.

 

*Job Title (check one) Benefits Counselor Case Manager Dietician Health Educator Mental Health Counselor Outreach Worker Peer Advocate Prevention Worker Registered Nurse Substance Abuse Counselor Treatment Advocate/Educator Volunteer Other:	Your Field(s) of Work (check all that apply) Advocacy Benefits Faith-based Family Services Health Clinic Health/Medical Provider HIV/AIDS Prevention HIV/AIDS Case Management HIV/AIDS Education Housing Mental Health Substance Use Other:
Approximate HIV+ Caseload? Less than 10% 10-25% 26-50% 51-75% 76-99% 100%

Years in human service field?

Years specifically working in HIV/AIDS?

Do you provide direct services?

Do you supervise people?

Is CSTEP required for your job?

Yes
No

Any special needs for the training?


Please note: enrollment is NOT confirmed until written or verbal confirmation is received from CSTEP.
Please call to confirm registration and date.

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