Rhode Island Community Planning Group For HIV Prevention

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Rhode Island Community Planning Group For HIV Prevention

About Project REACH - Registration Form


Name
REQUIRED

(as you would like it to appear on your certificate)

Agency

Address

City

State/Prov

Zip

Last 4 digits
of your SS#

Work Phone

Home Phone

E-Mail
REQUIRED

COURSE TITLES

DATES

DEPOSIT

What is your field/profession? PLEASE CHOOSE ONE.

 

HIV Prevention Professional

 

HIV Case Manager

 

Nurse

 

Substance Abuse Counselor

 

Physician

 

Program Director/Administrator

 

Social Worker

 

Clinical Director/Supervisor

 

MH Counselor

 

State Agency Representative

 

Psychologist

 

Outreach Worker

 

Other (please specify at right)

Are you on the RICPG?

CPG Member

Task Force Member

Not a Member

Would you like to opt out of receiving paper catalogs in the future?

Yes

No

Please send deposit(s) to:
Project REACH
102 Dupont Dr.
Providence, RI 02907


© Copyright RI Community Planning Group for HIV Prevention. All rights reserved.
RICPG.ORG • PO Box 435 • Foster, RI 02825 • (401) 397-5616

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