HIV/AIDS 500-501 Pre-Registration Form | Forms

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 Lisa.Quammie-John@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 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):*

E-Mail 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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