Peer Educator’s Training
August 1 – 4, 2005
Name:
____________________________________________________________________________
Last First Middle (nickname for badge)
□ male □ female age: ______________ ssn# _______________________
Address:
__________________________________________________________________________
_______________________________________________________________________________________________________________
Parent/Guardian: ____________________________Email:
________________________________
Telephone: ____________________________________ Cell: ______________________________
Sponsoring Agency/School:__________________________________________________________
Contact Person: ____________________________________________________________________
Address:
__________________________________________________________________________
_______________________________________________________________________________________________________________
Telephone: ____________________________________ FAX: ______________________________
Email:
____________________________________________________________________________
Transportation
Provided By:_________________________________________________________
Community
Coalition Training
Phone:
904-682-3912 FAX: 904-682-3724
Please email/fax registration form to
Internal Use
Interviewed By: ___________________________ Date:________________
Remarks:
_________________________________________________________________________
__________________________________________________________________________________
□ accepted □
agency/school notified