ADVOCACY

C2P2 EEL - Apply for 2012 Sessions

APPLICATION—Please complete the form below

Application deadline: January 27, 2012

Session Dates: 2012 - February 10-11, March 23-24, April 20-21, June 1-2, September 7-8.

Questions? Contact Kathy Miller, Assistant Director of Training, 215-204-3031, Telephone: 215-204-9395, Voice/TTY: 215-204-1356, Email: millerk@temple.edu.

To apply: Please complete the form below and submit by January 27, 2012.

Items marked with * are required.

*First Name:

*Last Name:

*Date of Birth:

*Address Line 1:

Address Line 2:

*City:

*State:

*Zip:

*Home Phone:

Business Phone:

Cell Phone:

Email Address:

*Are you applying as an Emerging Leader or an Established Leader? Select one:
Emerging Leader
Established Leader

*Why are you interested in participating in C2P2 EEL training? Did a specific issue encourage you to apply?:

*Are you currently employed?
No
Yes

If yes, where are you employed?:

If there are any special arrangements necessary for you to participate in this program, please describe (accessibility, interpreters, personal assistance services, respite, etc.):

*Tell us a little about yourself:

List two references and provide the following information:

*Name 1:

*Phone 1:

Email 1:

*Name 2:

*Phone 2:

Email 2:

How did you hear about this program, C2P2 EEL?: