POCCETS Registration Form

Please complete the form in its entirety. All fields are required. 

    Agency Name

    Agency Address

    Contact Person/ Name of the person completing this form

    Your Role or Position in Agency

    Phone

    Email Address (required)

    In order to maximize the benefits of POCCETS, your agency and staff must commit to the entire program prior to registering. Is your agency willing and able to commit to sending staff representatives, as outlined in the Training Schedule, to each of the above dates and times?
    YesNo

    Please list the anticipated staff attendees for each course:

    Course 1

    Name
    Role
    Email
    Phone

    Name
    Role
    Email
    Phone

    Name
    Role
    Email
    Phone

    Course 2

    Name
    Role
    Email
    Phone

    Name
    Role
    Email
    Phone

    Name
    Role
    Email
    Phone

    Course 3

    Name
    Role
    Email
    Phone

    Name
    Role
    Email
    Phone

    Name
    Role
    Email
    Phone

    Course 4

    Name
    Role
    Email
    Phone

    Name
    Role
    Email
    Phone

    Name
    Role
    Email
    Phone

    Course 5

    Name
    Role
    Email
    Phone

    Name
    Role
    Email
    Phone

    Name
    Role
    Email
    Phone

    If any of the above listed staff members are unable to attend, please be prepared to designate an alternative representative and notify CultureConnections as soon as possible. If you are unsure which role/positions are best to send to each course, we encourage you to contact Michal Milow at 973-323-3454.

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