HIV/AIDS 500-501 Pre-Registration Form

HIV/AIDS 500 ONLINE and 501 ONLINE Certificates of Completion are required with pre-registration form and cannot be longer than six months prior to registration. Please send BOTH certificates and signed Participant Agreement to Lori.Jordahl@flhealth.gov. Registration deadline is one day prior to training date; unless training reaches capacity. A registration link via GoTo Training will be sent to all registered participants...

TRAINING PRE-REGISTRATION FORM

Training Date Requested (Seleccione la fecha del curso) *

Testing Site Information (Datos de la institución donde se efectúa la prueba)

Name of Agency (Nombre de la institucion donde se realiza la prueba) *

Site Number (Código [#] de la Agencia)

Participant Information (Datos del solicitante)

Name (Nombre completo) *

Email Address (Correo electrónico) *

Phone Number (Teléfono) *

Name of participant’s Supervisor (Nombre del supervisor del solicitante)

Print Name (Nombre)

Name of Certified Counselor if different from Supervisor (Nombre del Consejero Certificado si es diferente al del Supervisor)

Print Name (Nombre)

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