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Training Application

Please submit this form at least 2 months prior to your desired training date.

Tailored Training Application Form

Contact First Name*

Contact Last Name*

Title*

Organization*

Address 1*

Address 2

City*

State*

Zip*

Phone Number*

Fax

Email Address*

Contact Information

How do you prefer to be contacted?

Phone Fax Email

Workshop Information

Are you selecting a workshop from SHIFT NC's list of available trainings?*

Yes No

If you checked yes, please specify the training:

If you checked no, what would you like the focus of the training to be?

Preferred date and time*

Please be specific about your requested time.

Alternate date and time*

Please be specific about your requested time.

Training location *

Please include location specifics, as well as city and county.

Target audience*

Please tell us as much as possible about the target audience.

Is pre-registration required? *

Yes No

If yes, registrar's name

Registrar's phone

Registrar's email

Is your workshop open to others?

If your workshop to others outside of your organization, we can create an online registration page.

Yes No

Estimated number of participants*

Maximum room capacity

Shipping Information (For Materials)

ATTN:

Shipping Address

Your contribution can help young people grow up healthy!

Any Amount Makes a Difference!

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