HIV, Substance Abuse and Co-occurring Disorders
REGISTRATION FORM
If for any reason you cannot use this form to register for the training, please contact Margot Kirkland-Isaac at mkirkland-isaac@dccare.org or call 202-223-9550 ext. 208 with your name, affiliation, address and phone number and the training for which you would like to register.

There is limited parking in the area.  If possible, please consider taking public transportation. The Takoma Metro Station is located two blocks from our office.
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DC CARE GENERAL PHOTOGRAPHY RELEASE STATEMENT *
Do you authorize DC CARE to publish photographs taken of you on August 31, 2016 and your name and likeness, for use in DC CARE's print, online and video-based marketing materials, as well as other DC CARE publications?
Required
First Name *
Last Name *
Title/Job Position *
Agency *
Degree/License
Agency Type
Agency Primary Target Population(s) *
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Email Address *
Street Address *
City *
State *
Zip *
Telephone Number *
Fax Number
If you are a Social Worker licensed in Washington D.C. Metropolitan Area, what is your license number?
YOU WILL NOT RECEIVE CEUS IF THIS PORTION IS NOT FILLED OUT
If you are a Social Worker licensed in Washington D.C. Metropolitan Area, what is your license expiration date?
YOU WILL NOT RECEIVE CEUS IF THIS PORTION IS NOT FILLED OUT
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If you are a Nurse licensed in Washington D.C. Metropolitan Area, what is your license number?
YOU WILL NOT RECEIVE CEUS IF THIS PORTION IS NOT FILLED OUT
If you are a Nurse licensed in Washington D.C. Metropolitan Area, what is your license expiration date?
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