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Culturally and Linguistically Appropriate Services (CLAS) Training for Providers
Please complete each section to register for our new provider training and orientation.
*
1.
Practice Information.
(Required.)
Provider, Group, or Facility Name:
Address 1:
Address 2:
City/Town:
State:
ZIP Code:
Email Address:
Phone Number:
Fax Number:
Tax ID Number:
2.
Main Contact for Practice
Name:
Title:
Phone Number:
Email Address:
*
3.
Please choose the date and time of the training you will be attending
(Required.)
Thursday, 09/29/2023 at 12 Noon
Thursday, 12/14/2023 at 12 Noon
Thursday, 03/21/2024 at 12 Noon
Thursday, 06/20/2024 at 12 Noon
Thursday, 09/19/2024 at 12 Noon
Thursday, 12/12/2024 at 12 Noon
4.
Please list the names of the practice or facility staff and/or practitioners who will be attending the scheduled training.
Provider Name:
Provider Name:
Provider Name:
Provider Name:
Provider Name:
Provider Name:
Provider Name:
Provider Name:
Provider Name:
Provider Name:
