WV COUNCIL FOR THE PREVENTION OF SUICIDE TRAINING

REGISTRATION FORM

Name: __________________________

Address: _______________________________________

City: _____________ State: _____________ Zip Code: _____

Work Phone: ______________ Home Phone: ________

E-mail address: ______________@___________

What agency do you represent?

Mental Health Law Enforcement ____

Senior Citizen DHHR ____

Education Juvenile Justice ____

Clergy Domestic Violence ____

Public Health Other: _________________

Community

CEU’s?

License: Social Work

Nursing

LPC

CAC

CHES

Domestic Violence

Law Enforcement

Psychology

Location of Training: __________________

Are you willing to become a trainer in your community? Yes No

$15.00 Paid ____

Checks may be made out to Valley Healthcare System