S/N Clinic Mentorship Follow-up Training Application
NSNRT Clinic Name *
Your answer
Clinic City *
Your answer
Clinic State *
Clinic Zip Code *
Your answer
Your Name *
Your answer
Your Title *
Your answer
Contact Phone *
Your answer
Contact Email *
Your answer
General Timing
Preferred Dates *
Please let us know if you have special requests in terms of timing or specific days of the week.
Your answer
Full Attendance *
Will all of your team attend in one sitting? If you need your team to come in shifts, please complete this request form for each shift.
Your Medical Team
Your veterinarian will need to obtain a North Carolina temporary license. Details will be sent once dates have been confirmed.

In Humane Alliance terms, a veterinary technician (licensed or not) is the person who handles the controlled substances, does intubations, and injections. A veterinary assistant is primarily responsible for patient prepping and patient care.

Staff #1 First Name *
Your answer
Staff #1 Last Name *
Your answer
Staff #1 Email *
Email address of program participant (to reach in case of emergency)
Your answer
Staff #1 Phone *
Cell phone of program participant (to reach in case of emergency)
Your answer
Staff #1 Position *
Time in Position *
How long has this person been in this position, i.e. 3 months
Your answer
Primary Duties *
Please list primary duties/responsibilities for this person
Your answer
Repeat Training *
Has this staff member previously attended training at Humane Alliance?
Staff #2 First Name
Your answer
Staff #2 Last Name
Your answer
Staff #2 Email
Please use a personal email address
Your answer
Staff #2 Position
Time in Position
How long has this person been in this position, i.e. 3 months
Your answer
Primary Duties
Please list primary duties/responsibilities for this person
Your answer
Repeat Training
Has this staff member previously attended training at Humane Alliance?
Staff #3 First Name
Your answer
Staff #3 Last Name
Your answer
Staff #3 Email
Please use a personal email address
Your answer
Staff #3 Position
Time in Position
How long has this person been in this position, i.e. 3 months
Your answer
Primary Duties
Please list primary duties/responsibilities for this person
Your answer
Repeat Training
Has this staff member previously attended training at Humane Alliance?
Staff #4 First Name
Your answer
Staff #4 Last Name
Your answer
Staff #4 Email
Please use a personal email address
Your answer
Staff #4 Position
Time in Position
How long has this person been in this position, i.e. 3 months
Your answer
Primary Duties
Please list primary duties/responsibilities for this person
Your answer
Repeat Training
Has this staff member previously attended training at Humane Alliance?
Staff #5 First Name
Your answer
Staff #5 Last Name
Your answer
Staff #5 Email
Please use a personal email address
Your answer
Staff #5 Position
Time in Position
How long has this person been in this position, i.e. 3 months
Your answer
Primary Duties
Please list primary duties/responsibilities for this person
Your answer
Repeat Training
Has this staff member previously attended training at Humane Alliance?
Additional Comments
Your answer
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