ONLINE South Bay EFT Externship Registration Form

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January 30 & 31, 2021 and February 13 & 14, 2021

Name (first & last) *

License #

Email address *

Mailing address (Street) *

City, State, Zip *

Phone Number *

Paid by: *

PayPal/Credit Card

Venmo (@Nancy-Aikin)

Other:

Check the boxes below to indicate your agreement with each statement: *

"I agree to not record any part of this training in any format (audio, video, or visual). Personal written notes of non-confidential material are permitted."

"I have the educational training, qualifications, and professional credentials to practice as a mental health professional in the area where I live or I am in a formal training program of supervised internship to become a mental health professional."

"I agree to keep confidential the personal identifying information of case material shared in the training."

Required

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