Engaging Families and Young Adults Program Training Confirmation Form

Name*

Email*

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

We will mail you a hard copy of the Serving on Groups Guide, which you need for the Serving on Groups training.

We will mail you a hard copy Serving on Groups Guide, which you need for the Serving on Groups training. If you want this Guide sent to you at an address that is different than the one listed above, please share it here:

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please list any accommodations you may need here:

Young Adult Advisor (must be aged 18-26 and participating on behalf of yourself)Family Advisor (must be 18+ and be participating on behalf of a family member)

March Option: Saturday, March 14th and Saturday, March 21st (9:00 a.m.–11:30 a.m. each date)May Option 1: Tuesday, May 5th and Thursday, May 7th (4:00 p.m.–6:30 p.m.)May Option 2: Thursday, May 14th and Thursday, May 21st (1:00 p.m.–3:30 p.m.)I have already completed Serving on Groups training, and only need to schedule Optimal Health for All training.None of the above options work for me, and I will need to schedule this training in the next quarter.

March Option: Thursday, March 5th (4:30 p.m.–7:30 p.m.)April Option 1: Thursday, April 16th (4:30 p.m.–7:30 p.m.)April Option 2: Saturday, April 25th (9:00 a.m.–12:00 p.m.)I have already completed Optimal Health for All training, and only need to schedule Serving on Groups training.None of the above options work for me, and I will need to schedule this training in the next quarter.

Arizona Department of Health Services (ADHS)Diverse Ability IncorporatedEncircle FamiliesOther

Below, please share any specifics you can about the previous questions, such as: name of ADHS department, or name of person who referred you. This information will help ensure that we are connecting all the dots regarding your service opportunity.