*First Name:	*Last Name:
*Day Phone:	Fax:
*E-mail:
Organization:
*Mailing Address:
*City:		*State:		*Zip:
*Supervisor's Name:
*Supervisor's E-Mail:
*Supervisor's Phone:

*Have you attended a CSTEP training before? Yes  No
If Yes, please list trainings and dates:

*Is this training a requirement to perform/continue to perform your job at your agency? Yes  No
If Yes, please explain. If No, then what is your main reason for participating in this training?

* 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 30-31, 2013 9 a.m.-5 p.m.

San Diego

Treatment II

Family Health Centers of San Diego 3514 30th Street San Diego, CA 92110

 

County in which you currently provide services:	Primary Employment Setting: Rural Suburban Urban
Please select the population(s) that you provide services for at your agency: (select all that apply) African-American Asian Latino/a Native American Pacific Islander Caucasian/White Other:	Please select the primary population that you provide services for at your agency: (select ONLY one) African-American Asian Latino/a Native American Pacific Islander Caucasian/White Other:
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 total agency's clients identify as LGBT (Lesbian, Gay, Bisexual, Transgender): Very few (i.e., less than 10%) Less than half (10% - 50%) More than half (50% - 90%) Almost all (> 90%) N/A
Approximate HIV+ Caseload? Less than 10% 10 - 25% 26 - 50% 51 - 75% 76 - 99% 100%	Is your agency Ryan White-funded? Yes No Don't Know/Not Sure
*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:	Years specifically working in HIV/AIDS. Less than 1 year 1 - 3 years 3+ - 5 years 5+ - 10 years 10+ years

For Benefits Training participants ONLY, do you help clients with enrollment in public benefits? If so, please check all that apply.
Medicare
Medi-Cal
SSI (Supplemental Security Income)
SSDI (Social Security Disability Insurance)
SDI (State Disability Insurance)
ADAP (AIDS Drug Assistance Program)
LIHP (Low Income Health Program)
Other:

I do not help with enrollment of public benefits

For Treatment Training participants ONLY, how much of your time (if any) is spent providing HIV education and/or treatment information to people living with HIV/AIDS?
Less than 10%
10 - 25%
26 - 50%
51 - 75%
76 - 99%
100%

Please let us know what you would like to get out of this training: (optional)



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