TGH CHA Course Details Form
This form should be completed ONLY if you have already received approval after submitting a Course Request form. Please complete the entire form. If you have questions, contact Sammy at sammy@techgoeshomecha.org.
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Trainer Name *
Trainer Title/Position (at your institution/community organization) *
If you have any co-trainers, please enter those names here.
Please note that ALL trainers must fill out individual applications.
Trainer Email *
Please include the best email for us to contact you.
Trainer Telephone Number *
(xxx) xxx-xxxx
Have you been a TGH CHA trainer in the past? *
Trainer Agreement *
I agree to accept responsibility for my full participation in Tech Goes Home CHA as stated in the requirements.  I confirm that I have  completed a Trainer Training course with TGH CHA staff, and I understand that I will work with my colleagues at my site and TGH CHA staff to support all TGH CHA expectations.
Required
Media Release *
I hereby give the unqualified right to the TGH CHA program to take pictures and/or video of me while participating in my course. I give permission for these images as well as materials that we have created in the TGH CHA program to be used in print and web-based publications. The TGH CHA program will put these images to legitimate use without limitation or reservation.
Training Site & Course Info
During which Program Term will your course take place? *
Which type of TGH CHA course will you be teaching? *
Course Location *
Please include the full name of the site or organization.
Classroom Location *
Room #, Street Address, City, Zip (or "virtual")
Training Location Telephone Number *
(xxx) xxx-xxxx    Number participants should call to get information about the class. We do not recommend using your personal number as we will be putting this info on the TGH CHA site.
Number of participants or student/caregiver pairs your site will accommodate
This is generally limited by the number of computers available. Please limit School courses to no more than 15 families and Community/Early Childhood courses to 20 or less.
Population Being Served *
Please select all that apply. If you are teaching a course to families that speak languages other than English or Spanish, please select "Other" and enter the language(s). If you are uncertain at this time, please make an educated guess.
Required
Language(s) in which course with be taught *
Check all that apply.
Required
What age(s) will you be teaching? *
You can check more than one. If you are uncertain at this time, please make an educated guess and also check TBD.
Required
Would you like a volunteer in your course with any of the following skills? *
Check all that apply, and we will do our best to meet your needs.
Required
Do you need to pre-order devices for use during your course? *
If you do NOT have CHROMEBOOKS for participants to use at your site, then you MUST pre-order. All Early Childhood sites MUST pre-order. Please remember that device orders must be submitted at least 2 wks before the requested delivery date.
What is your application deadline for participants to apply for your course? *
Course Dates & Times
Course dates should correspond to the Program Term you selected above.
Total course time must be at least 15 hours, and no single class can exceed 3 hours.
These times can be modified later, but please be as specific and accurate as you can.
First Class Date and Time *
ex. Oct 16 4-6pm
Last Class Date and Time *
What day(s) of the week will class meet? *
ex. Mondays & Wednesdays
How many total class days will you meet? *
Make-up Date and Time *
Please indicate the date/time when you will offer a scheduled make-up class, or if you will schedule on an as-needed basis.
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