INDIVIDUAL/FAMILY REGISTRATION

Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County?
Phone Number*
Please note: agency may send text messages surrounding training request.
Email*
example@example.com
The creator of this training program, the Addiction Policy Forum, requests we submit a participant list that includes email addresses for purposes of sending a PRE and POST survey ONLY. They do not use these emails for any purpose beyond continued data collection surrounding the program’s impact. Please check the box to permit Branches LLC to submit your email address to AFP. *
License number (if applicable):
If CEU's are needed or applicable. Ohio Counselor, Social Worker and Marriage and Family Therapist Board and Ohio Chemical Dependency Professionals Board approved provider.
Are you registering for an already scheduled training or requesting to be included at future training opportunities? Please input your preferred date/time for the training below if you aren't registering for an already scheduled training.
Please list below.*
If registering for an already scheduled training, lunch or refreshments may be offered.
Any dietary requirements or special needs? List below.
Agency you are affiliated with, if applicable:
Interest in attending a training:*
List your interest in attending. For example; family member of a person in recovery, in recovery yourself, etc.
How did you hear about these training opportunities?*
Should be Empty: