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Name
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Last
As it should be listed on our website, including credentials
Title & Organizational Affiliation
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Brief Bio
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Please include a few lines to a paragraph, including relevant trainer information
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I am interested in providing these trainings (please check all that apply)
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Trauma 101
Trauma 102
Trauma 103
Trauma 107
Trauma 108
I or my organization will support the Lakeside licensure fees to become a licensed Adjunct Trainer for these trainings (please check all that apply)
*
Trauma 102, $250
Trauma 103, $500
Trauma 107, $500
Trauma 108, $500
All of the above, $1,500
I will not be able to become licensed without financial support from the Bucks-Mont Collaborative. Please select from the dropdown menu.
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Note: Financial support is not guaranteed, as we are seeking a funder to support some licensure fees. Thank you!
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