CAPP & PREP: Request form for 2 online courses

Use this survey to request log-in information for these online courses only:

Implementing Evidence-Based Programs: an Online Training for Educators, and/or
Health Educator Supervisor online training

Please complete a separate survey for each person to be registered.

Please note that this form will not register you automatically -- ACT for Youth will complete the registration for you. When your request is processed, the person registered will receive course log-in information by email.

Full name of CAPP or PREP agency:

Name of person to be registered:

Email address of registrant:

Registrant's position for CAPP or PREP

Educator (EBP facilitator)
Health Educator Supervisor
Other (describe)

Which training(s) do you wish to register for?

Implementing Evidence-Based Programs: an Online Training for Educators (required for all CAPP and PREP educators)
Health Educator Supervisor online training

Name and email address of person making request (if other than registrant)