Name of organization:

Contact person:

Job title:

Street address:

City: State: Zip:

Phone Number:

Fax Number:

Email:   

2. Request Training Services

Would this training be part of an already-scheduled event?  Yes  No

If this training will be part of an already-scheduled event, what is the event name? 

Where will the training be held?

How far is the location from Minneapolis/St. Paul? miles

On what date do you want to hold the training?

Is the date flexible? Yes  No

Time (if known): Select one morning afternoon evening weekend Other (specify):

Select a training topic: Select one Bridging Education and Mental Health CLASS Awareness and Overview Session Environmental Rating Scales (ERS) Training IGDIs and Get It! Got It! Go! Introduction to Infant Mental Health Reflective Supervision Relationship-based Work with Young Children: Engaging Families Seeing is Believing (only) STEEP (only) STEEP/SIB Combined Training Supporting Stressed Young Children

Approximately how many participants will there be? Select one 1-10 10-25 25-50 50-75 75-100 100+

What are the participants' levels of knowledge about the topic? Select one Beginner Intermediate Advanced Mixed

What are the three to five major areas of interest regarding the topic?

1.

2.

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5.

Yes, I have reviewed the training terms and fees.

Additional Comments:

Please check to see that you have fully completed the Contact Information and Service Request sections. Then click the "Submit" button to send your request. You will receive a confirmation email that your request was successfully submitted. This form is an inquiry and does not commit you to services. Our Training Services staff person, Andrea Peterson (peter327@umn.edu, 612-625-1464) will contact you to follow up on your request.