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

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.

	Date	City	Training	Place
	August 18, 2008 9am - 12pm Topic: HIV & Hep C	Los Angeles	Up-To-Date (English)	The California Endowment-LA 1000 N. Alameda Street Los Angeles, CA 90012
	August 18 , 2008 1pm - 5pm	Los Angeles	Re-Certification (English)	The California Endowment-LA 1000 N. Alameda Street Los Angeles, CA 90012
	August 19-20, 2008 9am - 5pm	Los Angeles	Basics (English)	The California Endowment-LA 1000 N. Alameda Street Los Angeles, CA 90012
	September 24-25, 2008 9am - 5pm	Sacramento	Basics (English)	CARES, 1500 21st Street, Sacramento, CA 95814.
	September 26, 2008 9am - 5pm	Sacramento	Up-To-Date (English)	CARES, 1500 21st Street, Sacramento, CA 95814.
	September 26, 2008 9am - 5pm	Sacramento	Certification (English)	CARES, 1500 21st Street, Sacramento, CA 95814.

 

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.