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WMR Application

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Contact Information:
First Name:   *  
Last Name:   *  
Address:   *  
City:   *  
State:   *  
Zip Code:   *  
County:   *  
Work Phone:
Home Phone:   *  
Cell Phone:
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Workshop Information:

General

Which number is best to use during daytime hours? (8:30 a.m. - 5:30p.m.)

Employer or representing organization

Role/Job Title

To what organization will the CEUs be reported:

Will you apply for continuing education units (CEU)?
 Yes  No  Not Answered (*Please choose another option other than not answered)

How did you hear about this training?

Are you a vegetarian?
 Yes  No  Not Answered (*Please choose another option other than not answered)

Are you diabetic?
 Yes  No  Not Answered (*Please choose another option other than not answered)

Do you have a specific food allergy?
 Yes  No  Not Answered (*Please choose another option other than not answered)

If yes, describe:

Do you have any other dietary needs?
 Yes  No  Not Answered (*Please choose another option other than not answered)

Which instructor teach back day will you attend?
 July 1, 2009 at Public Strategies, 301 N.W. 63rd Street, Suite 105, OKC, OK  July 2, 2009 at Youth Services of Tulsa, 311 S. Madison, Tulsa, OK 74120  Not Answered (*Please choose another option other than not answered)

Where will you conduct your workshops?

When will you conduct your first workshop and future workshops?

How will individuals be recruited to your workshop?

Who will be co-leading Within My Reach workshops with you?

Please tell us about your agency or program and the general demographics of the population to whom the services would be delivered.
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