Community Health Training Center - Registrations, Training Request Form

Trainee Name: ________________________

Title: ________________________________

Credentials (i.e. RN, RD) : _______________

Training Name: _______________________

Course Code: _____

Date Requested: __________

Site: ________________________________

Agency Name: ________________________

Address: _____________________________

__________________________

Telephone: ___________ Fax: ___________

Supervisor’s Name: _________________

Return form to:

Springfield Site Community Health Training 100 N. 11th Street Springfield, IL 62708-3865 Attn: Marlin Hollis Telephone: 217-753-4066 Fax: 217-753-8939	Chicago Site Community Health Training Center 2850 S. Wabash Avenue Suite 204 Chicago, IL 60616-3271 Attn: Roberta Pondexter Telephone: 312-326-4701 Fax: 312-326-4704