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Training Request
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Name
*
First
Last
Organization (if applicable)
Job Title / Position
Email
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Enter Email
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Phone Number
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TRAINING DETAILS
Which type of training are you interested in?
*
(Select all that apply)
Emerging Clinicians Training
Practicing Clinician Training
Community Group Training
Black Women’s Health Sister Circle
Other
Specify Other Training Type
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Preferred format for this training?
*
In-Person
Virtual
Hybrid
What is the primary goal of this training?
*
(e.g., to educate about health disparities, improve health communication, foster community engagement, etc.)
How many participants are expected to attend?
*
(Estimate or exact)
Who is the intended audience for this training?
*
(Select all that apply)
Emerging Clinicians (students, new professionals)
Practicing Clinicians (experienced professionals)
Community Members
Other
Specify Other Audience
*
What is your preferred or intended date for the training?
*
(Please specify the desired date or range of dates.)
How much time is allocated for the training?
*
(e.g., 1 hour, half day, full day, etc.)
Does your organization intend to offer Continuing Education Units (CEUs) for this training/in-service?
*
Yes
No
Unsure
Will your organization be offering an honorarium for the training?
*
Yes
No
Unsure
Additional Comments/Questions
*
(Please share any additional details or questions you may have regarding the training.)
