*First Name:	*Last Name:
*Job Title:
Organization:
*Mailing Address:
*City:		*State:		*Zip:
*Day Phone:	Fax:
*E-mail:

* Required Fields

Below is the list of training dates. Please note that these dates are subject to change, so please verify times and dates beforehand.

You may sign up for more than one type of training.

	September 17, 2010 9:00am–5:00pm	San Francisco	Treatment: Re-Certification (English)	Asian & Pacific Islander Wellness Center 730 Polk St, 4th Floor San Francisco, CA 94109
	September 30 - October 1, 2010 9:00am–5:00pm	Pasadena	NEW! Benefits: Certification (English)	ASC 909 S. Fair Oaks Ave. Pasadena, CA 91105
	October 6, 2010 1:00pm–5:00pm	San Francisco	Benefits: Immigrant Issues (English)	Asian & Pacific Islander Wellness Center 730 Polk St, 4th Floor San Francisco, CA 94109
	October 21, 2010 9:00am–5:00pm	Fresno	NEW! Benefits: Basic (English)	TBD
	November 17 - 19, 2010 9:00am–5:00pm	San Diego	Treatment: Certification (English)	TBD
	December 2, 2010 9:00am–5:00pm	San Diego	NEW! Benefits: Basics (English)	TBD

 

*Job Position (check one) Benefits Counselor Case Manager Outreach Worker Health Educator Peer Advocate Nurse Physician Clergy/Faith-Based Professional Dietician/Nutritionist Mental Health Professional Public Health Professional Social Worker Substance Abuse Professional Volunteer Other:	Approximate HIV+ Caseload? Less than 10% 10 - 25% 26 - 50% 51 - 75% 76 - 99% 100% Largest ethnic group served? African-American Asian Latino/a Native American Pacific Islander Caucasian/White Other:
Primary Employment Setting: Rural Suburban Urban	Please estimate (roughly) what percentage of your total agency's clients are persons of color. Very few (i.e., less than 10%) Less than half (10% - 50%) More than half (50% - 90%) Almost all (> 90%)
Please estimate (roughly) what percentage of your clients are women. Very few (i.e., less than 10%) Less than half (10% - 50%) More than half (50% - 90%) Almost all (> 90%)	Please estimate (roughly) what percentage of your clients are incarcerated population. Very few (i.e., less than 10%) Less than half (10% - 50%) More than half (50% - 90%) Almost all (> 90%)
Years of experience in Human Service field. Less than 1 year 1 - 3 years 3+ - 5 years 5+ - 10 years 10+ years	Years specifically working in HIV/AIDS. Less than 1 year 1 - 3 years 3+ - 5 years 5+ - 10 years 10+ years

Do you provide direct services? Yes No

Do you supervise people? Yes No

Is CSTEP required for your job? Yes No

Any special needs or questions for the training?


Please note: enrollment is NOT confirmed until written or verbal confirmation is received from CSTEP.
Please call to confirm registration and date.