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WI CHW Training Submission Form
Professional Development Opportunity
*
1.
Contact Information of Person Submitting form (this information will not be made public, only collected for questions from the curriculum and training committee)
(Required.)
Name (first and last)
Company/Agency
Address
Address 2
City/Town
State/Province
ZIP/Postal Code
Country
Email Address
Phone Number
2.
Resource Link
*
3.
Cost of Training?
(Required.)
*
4.
Training Date(s)?
(Required.)
Date:
Date:
Date:
*
5.
Time of Training?
(Required.)
Time:
Time:
Time
*
6.
Is there a Certificate of Completion offered?
(Required.)
Yes
No
Continuing Education Units (CEUs)
*
7.
Location of Training
(Required.)
Virtual
Hybrid
In-person (If in-person, please provide location)
Location if applicable: