Tri County Play workshop request form 2024

Requester's name*

MR. / MS. / ETC.FIRST NAMELAST NAME
Requester's email*
Requester's work number*

AREA CODEPHONE NUMBER
Requester's mobile number*

AREA CODEPHONE NUMBER
Is the requester also the workshop coordinator / the logistical contact for our trainer?*

YesNoOther
Host organization*
Location / venue*
Location address*

YOUR STREET ADDRESS OR PO BOX

CITYSTATE

ZIP
Event or conference name (if applicable)
Proposed workshop date*

MonthDayYear
Proposed workshop time*

:AM/PM Option
Proposed workshop date, if the above is not available*

MonthDayYear
Proposed workshop time, if the above is not available*

:AM/PM Option
What training are you requesting?*

Child care training*Doula services / birthing and breastfeedingParenting support / parent cafeRace equity / anti biasReproductive health / contraceptive supportSocial justice storytelling for children / Beloved BooksTrauma informed care / mental healthTri County Play Collaborative / becoming a Play Partner or Wonder FunderOther
If you're requesting a child care training, please specify the topic:
If you're requesting a child care training, is DSS credit needed?

YesNoOther
Who is your target audience?*

Center-based child care staffChildrenCommunity-based organizationFamily child care staffHealthcare agencyLocal businessesParents & primary caregivers of young childrenPregnant mothersPublic school staffThe publicOther
Can you tell us a little about why you're requesting this workshop?*
How did you hear about this opportunity?
Should be Empty: