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	Register to Attend a Training     Contact Information First Name: Last Name: Title: Choose One Adoption Worker Allied Health and Vocational School Staff Attorney/Lawyers Case Manager Certified Nurse Practitioner(CNP) Certified Nursing Assistant (CNA) CLINIC ADMINISTRATOR Community Outreach Worker Crisis/Hot line Staff and Volunteers Detention Center/Jail/Probation/Prison Staff Doctor Domestic Violence Center Staff Emergency Medical Technicians Employee Assistant Personnel in the work place EXECUTIVE DIRECTOR FAMILY PLANNING COOR Foster Care Staff Foster Parent Health Care Clinic Staff Healthy/Head Start and Early Intervention Staff Homeless Center Staff Hospital Administrators ICWA Workers IN-SERVICE EDUCATION Indian Health Services Staff Information and Referral Provider Juvenile Court/Family Court Judges Licensed Professional Counselor Medical Student Medical Technician Military Personnel – Family Support units Nurse (RN/LPN) Nurse Midwife Nurse Practitioner (NP) NURSING DIRECTOR Nursing Student OB/GYN Office Staff other Pregnancy Counselor Protective Services staff (CPS) Psychologist Psychology Student Residential/Group Care Staff Runaway Programs/Shelters Staff School Counselor SOCIAL SERVICES DIRECTOR Social Work Student Social Worker/Counselor STAFF DEVELOPMENT DIRECTOR Substance Abuse Staff Teacher Teen/youth Worker Therapist/Mental Health Professional Volunteer Email Address: EX: you@organization.com     Organization / Facility Organization / Facility: Facility Classification: Choose One 330 Health Clinic Community Health Centers Family Planning Clinic Homeless/Domestic Violence Shelter Medical/Health Clinic Nonprofit Hospital OB/GYN Office -ACOG Public Health Department Public Hospitals Public Housing School Based Health Clinic Title X Clinic ------------------- Agency Mental Health Srv Provider/behavioral health College or University Court/Legal services Court/probation/corrections Crisis Pregnancy Centers Developmental Disabilities Services Faith Based Organization/Church For profit Hospital Foster Care Health Care Association Health Care College Information and Referral Service Migrant Health Centers Military Health Services Nursing/Medical School Other Private Doctor’s Office Private Foster/Adoption Agency Private Practice Mental health/behavioral health Public Child Welfare Agency (includes CPS) Public Economic services Regional Education Service Centers Residential/Group Care School School of Social Work -Sociology-Human Serv Student Teen and/or Family support/resource center Visiting Nurse/Home Health Does your facility receive Title X or Section 330 funds? Yes No A $50 stipend is available to employees of facilities funded by these sources. Unsure if your facility receives either type of funding? Check Here: Title X - http://www.opaclearinghouse.org/db_search.asp Section 330 - http://findahealthcenter.hrsa.gov/ Address: City: State: Select State Colorado Montana North Dakota South Dakota Utah Wyoming Zip: Phone: Fax:     Training Location & Date of Training Choose One Brookings, SD  Mar 22, 2012 Salt Lake City, UT  Apr 12, 2012 Would you be interested in inviting the training program to your organization? Yes     No How did you hear about the Infant Adoption Training Initiative? Choose One Brochure Co-Worker Conference E-mail Magazine Mailing Newspaper Other Phone Call Poster Website Work      Question or Comment
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