Prevention Extension Training Application Form

Please complete application 6 weeks prior to proposed training.

708 College Ave.
Santa Rosa, CA 95404

Phone: 1 (877) 568-4227
Fax: (707) 568-3810

A. APPLICANT INFORMATION
First Name*
Last Name*
Title*
Organization*
Address Line 1*
Address Line 2
City*
State	California
Zip Code*
County*
Phone*	( ) - Ext:

Fax	( ) -
Other	( ) -
Email*
Website
Will the requesting organization receive the training services?*	Yes No
If not, please include the contact information of the organization who will be receiving services.
Organization: (or indicate group to be served)
Address Line 1*
Address Line 2
City*
Zip Code*
Phone*	( ) - Ext:

Fax	( ) -
Other	( ) -
Email*
Website
State	California
Please check one of the following categories that best describes your organization: *	Business/Professional Association Board Coalition/Community Partnership Community-Based Organization County ADP Other County Agency City Agency State Agency Federal Agency Education K - 12 College Health Service Agency Law Enforcement Neighborhood/Housing Religious Organization FNL/Club Live Other
How did you hear about CPI Training services? (Please check one)*	Workshops/Brochure County Alcohol and Drug Program California Department of Alcohol and Drug Programs Colleague Previous Utilization Internet Consultant Regional Trainers Other
B. WORKSHOP SERIES REQUEST
Please choose workshop(s) you would like to host/sponsor.	Brief Intervention For Substance Using Adolescents Designing and Customizing Mentor Training Media Advocacy Basics Prevention 101: Foundations of Substance Abuse From Risk To Resilience: Inside-Out Prevention Grantwriting: Developing And Maintaining AOD Prevention Programs Part I & Part II Environmental Prevention: Strategies for Engaging Youth Responsible Beverage Service Public Policy 101: From Assessment to Enforcement Youth in Focus: Conducting Youth-Led Focus Groups
Click here to view the 2010 CPI Training Catalog for a complete list of available trainings.
2. List proposed training dates*
Approximately how many will be attending the workshop?
Would you be interested in having a follow-up training with some of the participants?*	Yes No
If yes, please describe:
Possible dates
C. WORKSHOP BACKGROUND
Who will be attending the workshop? (Check all that apply)*	Community members Prevention staff CBO staff County ADP staff Other
If other, please specify
Has training on this topic been offered to the proposed participants before?	Yes No
If yes, what were the outcomes?
Are there any current prevention projects or community efforts that could be used as examples by the trainer?*	Yes No
If yes, please describe:
Are there any topics in the proposed training workshop that you want emphasized by the trainer?*	Yes No
If yes, please describe:
Are you requesting a specific consultant?*	Yes No
If yes, please specify:
BY ACCEPTING TECHNICAL ASSISTANCE FROM CPI WE AGREE TO COMPLETE ALL EVALUATION DOCUMENTS AND RETURN TO CPI WITHIN 2 WEEKS AFTER RECEIPT.

Prevention Extension Training Application Form

A. APPLICANT INFORMATION

B. WORKSHOP SERIES REQUEST

C. WORKSHOP BACKGROUND