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Formulario para formadores voluntarios
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Formulario para formadores voluntarios
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Your Information
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Step
1
of 2
Name
*
First
Last
As it should be listed on our website, including credentials
Title & Organizational Affiliation
*
Brief Bio
*
Please include a few lines to a paragraph, including relevant trainer information
Photo
Click or drag a file to this area to upload.
This is an optional, upload field. If you choose to upload a photo, we will use that photo on our website.
Next
I am interested in providing these trainings (please check all that apply)
*
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.
*
Yes
No
Unsure
Note: Financial support is not guaranteed, as we are seeking a funder to support some licensure fees. Thank you!
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