POCCETS Registration Form

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.