Training Request Form

Trainee Name:

Title:

Credentials (i.e. RN, RD):

Training Name:

Course Code:

Date Requested:

Training Site:

Agency Name:

Address:

Address line 2:

City:

State:

Zip:

Phone:

Fax:

Supervisor's Name:

Supervisor's Email:

Trainee's Email:

Springfield Site

Community Health Training Center
100 N. 11th Street
Springfield, IL 62703
Attn: Cassandra Curry

Telephone: 217-753-3838 x200
Fax: 217-753-8939

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