REGISTRATION - Certified CIT Coordinator Course

Please complete the registration for the Certified CIT Coordinator Course. Preference will be given to those who are currently a CIT Coordinator for their Community CIT Program.

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* 1. Please complete the below:

Name

Agency/Organization

Mailing Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Cell Phone

Work Phone

Email Address

CIT Experience

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* 2. How many hours of CIT training have you completed? Please explain # of hours, when and where:

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* 3. For course attendees a completion of a 40 hour CIT training is desired. Please attach a copy of your certification of completion/attendance at a 40-hour CIT training, or a letter from your department or CIT trainers.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

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* 4. Current Position Details

Current Agency/Community CIT Coordinator

Plan to be a CIT Coordinator

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* 5. Professional Affiliation:

Law Enforcement/Corrections

Advocacy

Mental Health

Medical/Hospital

Other (please specify)

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* 6. Length of time as CIT Coordinator, if applicable? Please indicate the number of years and months .

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* 7. Please check below. By checking "Yes" you verify that you have reviewed the CIT Core Elements on the CIT International Website at: http://www.citinternational.org/Memphis-Model-Core-Elements and that you agree with and ADVOCATE for them

Yes