First Name:	Last Name:
Organization:
Mailing Address:
City:		State:		Zip:
Day Phone:	Fax:
E-mail:

Below is the list of training dates. Please note that these dates are subject to change, so please verify times and dates beforehand.

You may sign up for more than one type of training.

	Date	City	Training	Place
	April 21-23, 2009 9:00am-5:00pm	Palm Springs	Certification (English)	Desert AIDS Project, 1695 N. Sunrise Way, Palm Springs, CA 92262
	May 5-7 , 2009 9:00am-5:00pm Download Agenda (PDF)	Los Angeles Download Flyer (PDF)	Advanced (English)	The California Endowment, 1000 N. Alameda Street, Los Angeles, 90012
	June 16-18, 2009 9:00am-5:00pm Download Agenda (PDF)	Oakland	Certification (English)	The California Endowment 111 Broadway, 4th Floor Oakland, CA94607 This training is full Wait List Open

 

Gender: Male Female Transgender Decline to State

Sexuality: Gay Lesbian Heterosexual Bisexual Queer Decline to State

Ethnicity:

African-American Native American

Asian Pacific Islander

Caucasian/White Multi-Ethnic

Latino/a Other

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Job Title (check one) Benefits Counselor Case Manager Program Manager Health Educator Mental Health Counselor Outreach Worker Peer Advocate Prevention Worker Registered Nurse Substance Abuse Counselor Treatment Advocate/Educator Volunteer Other:	Your Field(s) of Work (check all that apply) Advocacy Benefits Faith-based Family Services Health Clinic Health/Medical Provider HIV/AIDS Prevention	HIV/AIDS Case Management HIV/AIDS Education Housing Mental Health Substance Use Other:
Approximate HIV+ Caseload? Less than 10% 10 - 25% 26 - 50% 51 - 75% 76 - 99% 100%	Largest ethnic group served? African-American Asian Latino/a Native American Pacific Islander Caucasian/White Other:
Please estimate (roughly) what percentage of your total agency's clients are persons of color.
Very few (i.e., less than 10%) Less than half (10% - 50%) More than half (50% - 90%) Almost all (> 90%)
Please estimate (roughly) what percentage of your clients are women.
Very few (i.e., less than 10%) Less than half (10% - 50%) More than half (50% - 90%) Almost all (> 90%)
Please estimate (roughly) what percentage of your clients are incarcerated population.
Very few (i.e., less than 10%) Less than half (10% - 50%) More than half (50% - 90%) Almost all (> 90%)
Years of experience in Human Service field.
Less than 1 year 1 - 3 years 3 - 5 years 5 - 10 years 10+ years
Years specifically working in HIV/AIDS.
Less than 1 year 1 - 3 years 3 - 5 years 5 - 10 years 10+ years

Do you provide direct services? Yes No

Do you supervise people? Yes No

Is CSTEP required for your job? Yes No

Any special needs or questions for the training?


Please note: enrollment is NOT confirmed until written or verbal confirmation is received from CSTEP.
Please call to confirm registration and date.