Crisis Intervention Training - Signup for June 1-5, 2015

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* 1. Please complete the following information for each attendee

Name: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Email Address: *

Phone Number: *

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* 2. What company or agency do you work for?

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* 3. Will this attendee need to have another staff member fill in for them on Overtime and will your agency be seeking grant funded reimbursement for that overtime expense?

No - We will not be seeking overtime reimbursement

Yes - We will be seeking overtime reimbursement (Fill in cost estimate below please)