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Prevention Workshop Agency Agreement
Requesting Agency: *
Point of Contact (POC): *
Address: *
Phone: *
Email: *
After hours/weekend POC Mobile Number: *
Type of Agency: *
Required
Number of attendees *
Workshop: *
Required
Mark (1, 2 & 3) for your top 3 choices in order of preference *
Required
Choose time (Saturday's only at 9 am) *
Required
Please give three dates with 1 being your first choice
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Second Date
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Third Date
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By checking the statements below the requesting agency agrees to the following requirements: *
Required
NOTE: Copy of agreement will be emailed to POC.
Special Note for Stewards of Children workshop: 90% of staff/volunteers MUST attend to be qualified to apply for Partner in Prevention seal.
Name of person submitting request: *
Date: *
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