West Virginia Stigma Training Request

West Virginia Stigma Training Request
Please use this form to request a West Virginia Stigma Training in your region. Please allow three weeks advance notice for scheduling. Contact jenny@stigmafreewv.org with questions.
Name*

First NameLast Name
Organization*
Email*
example@example.com
Cell Number*
Please enter a valid phone number.
Select region for your training*

Region 1: Brooke, Hancock, Marshall, Ohio, WetzelRegion 2: Berkeley, Grant, Hampshire, Hardy, Jefferson, Mineral, Morgan, PendletonRegion 3: Calhoun, Jackson, Pleasants, Ritchie, Roane, Tyler, Wirt, WoodRegion 4: Barbour, Braxton, Doddridge, Gilmer, Harrison, Lewis, Marion, Monongalia, Preston, Randolph, Taylor, Tucker, UpshurRegion 5: Boone, Cabell, Clay, Kanawha, Lincoln, Logan, Mason, Mingo, Putnam, WayneRegion 6: Fayette, Greenbrier, McDowell, Mercer, Monroe, Nicholas, Pocahontas, Raleigh, Summers, Webster, Wyoming
Who is your target audience?*
Preferred Training Date*

MonthDayYear
Date
2nd Choice Training Date*

MonthDayYear
Date
How much time is allocated for this training? (one hour, two days, etc.)
Will this training be held in-person or virtually?*

In-PersonVirtualHybrid - both in-person and virtual
Training Location*

Street Address

Street Address Line 2

CityState

Zip Code
Comments or Questions?
Should be Empty: