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