*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.

	May 23-24, 2012 9AM-5PM	Santa Clara	Benefits Certification	Community Health Partnership 100 N. Winchester Blvd. Suite 368 Santa Clara, CA 95050
	June 7-8, 2012 9AM-5PM	Los Angeles	Benefits Certification	Center for Healthy Communities Big Sur Room (Day 1), Mojave Room (Day 2) 1000 N. Alameda Street Los Angeles, CA 90012
	June 19-20, 2012 9AM-5PM	Los Angeles	Benefits Certification	Division of HIV and STD Programs 600 S. Commonwealth Avenue Room 907A Los Angeles, CA 90005
	June 21-22, 2012 9AM-5PM	Fresno	Treatment Certification	Community Health Center - Sierra Auditorium Room A 1925 E. Dakota Ave. Fresno, CA 93726
	June 28-29, 2012 9AM-5PM	Palm Springs	Benefits Certification	Desert AIDS Project Main Campus 1695 N. Sunrise Way Palm Springs, CA 92262

 

*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

Please write any special needs:



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