Lead Certification Class

Lead Certification Class

Greater Stark County Urban League
Student Lead Training Accreditation

** One form must be completed for each student and each class**

The Ohio Development Services Agency’s Office of Community Development (Development), partnering with the Ohio Department of Health (ODH) through the Training and Technical Assistance Grant Program for Lead Accreditation Training is to providing free training. The purpose of the Training and Technical Assistance Grant Program for Lead Accreditation is to optimize the lead workforce in Ohio by offering frequent, accessible, and affordable training opportunities. To receive this offer, you must be associated with, or willing to work with the Development and/or Health’s grant programs and attend the entire class session. I certify I am or are willing to work with Development and ODH program. I understand my information will be distributed to grant programs in the areas I have authorized.

(Information on this form is the student information)
Student Name

First NameLast Name
Company Name
Company Address
Student Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Phone type

CellWorkHomeOther
Student Email
example@example.com
Company Email
example@example.com
Birthday Date

MonthDayYear
Date
Only Last 4 Numbers of Social Security
Training Courses: (Check the actual class you want to take, remember a Lead Worker has to lead the class.

Ohio Department of Health (ODH) lead abatement contractor (Class Date / / )Ohio Department of Health (ODH) lead abatement workers (Class Date / / )Ohio Department of Health (ODH) lead inspector/risk assessor (Class Date / / )U.S. Environmental Protection Agency (EPA) Lead Renovation, Repair and Painting Rule (RRP Rule) Lead-Safe Renovator (Requested Class Date. / / )
Type of work interested in or currently performing for Development and/or ODH Grants: (Check all that apply)

Lead Abatement and Lead-Safe RenovationsLead Abatement onlyRRP/Lead-Safe Renovator onlyLead Risk AssessorGrantee/Administrator
Select the Counties in which you are willing to participate in Development and ODH grant programs. If you are willing to travel and work state-wide, please check the State-wide box below, or Not willing to work State-wide: (Remembering the program goal is to significantly increase the number of lead certified contractors & workers in Rural Ohio Counties)

State-wideNot willing to work State-wide - check or circle willing to work in on the map page. (Remember you have to check the counties, If State-wide box is not check)Type option 3Type option 4
Check the counties you are willing to work in, if State-wide box was not checked in previous question.

Adams CountyAllen CountyAshland CountyAshtabula CountyAthens CountyAuglaize CountyBelmont CountyBrown CountyButler CountyCarroll CountyChampaign CountyClark CountyClermont CountyClinton CountyColumbiana CountyCoshocton CountyCrawford CountyCuyahoga CountyDarke CountyDefiance CountyDelaware CountyErie CountyFairfield CountyFayette CountyFranklin CountyFulton CountyGallia CountyGeauga CountyGreene CountyGuernsey CountyHamilton CountyHancock CountyHardin CountyHarrison CountyHenry CountyHighland CountyHocking CountyHolmes CountyHuron CountyJackson CountyJefferson CountyKnox CountyLake CountyLawrence CountyLicking CountyLogan CountyLorain CountyLucas CountyMadison CountyMahoning CountyMarion CountyMedina CountyMeigs CountyMercer CountyMiami CountyMonroe CountyMontgomery CountyMorgan CountyMorrow CountyMuskingum CountyNoble CountyOttawa CountyPaulding CountyPerry CountyPickaway CountyPike CountyPortage CountyPreble CountyPutnam CountyRichland CountyRoss CountySandusky CountyScioto CountySeneca CountyShelby CountyStark CountySummit CountyTrumbull CountyTuscarawas CountyUnion CountyVan Wert CountyVinton CountyWarren CountyWashington CountyWayne CountyWilliams CountyWood CountyWyandot County
Student verification proof submitted for training verification:

Program currently working in an approved programCheck box and Submit Student Verification Proof for currently working in a program. Check/Invoice:Willing to work with programs - If you have Contacted a program, the Program Information below:
Should be Empty: