Region 7 Ohio PREP Provider Training Registration
Please complete all fields. You will receive an e-mail confirmation within 2-3 business days. If you have any questions or experience difficulty registering, please contact Region 7 Representative, Erin Lark 216-201-2001, ext. 1326 or elark@ccbh.net.
Please select the training date that you would like to register for *
First Name *
Your answer
Last Name *
Your answer
Licensure/Credentials *
Example: MSW; LICDC; N/A if none
Your answer
Email Address *
Your answer
Phone (Including Area Code) *
Your answer
Agency *
Your answer
Position/Title *
Example: Treatment Coordinator, Case Manager, etc.
Your answer
Supervisor *
Please provide your direct supervisor's name, phone number, and e-mail address
Your answer
County *
Please select the county/counties that your agency primarily operates in
Required
Are the youth served by your agency either in foster care or juvenile justice involved? *
Please select all that apply
Required
Please list any dietary restrictions *
Your answer
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