Child and Teen Checkups Training Request Form

Thank you for your interest in a Child and Teen Checkups (C&TC) training. Please complete this form to assist the C&TC team in planning a training to best meet your needs.

* = required

Contact Information of Requestor of Training (all required)

First Name: *

Last Name: *

Job Title: *

Email: *

Phone Number: *

Employer Name: *

City: *

County: *

Are you interested in attending, sending staff, or hosting a Standard C&TC Training (intended for all audiences) or Custom C&TC training (intended for those who provide C&TC screening exams: Clinics, Local Public Health and Tribes)? *

Attend a Standard Webinar and/or In-person C&TC Training
Send staff to a Standard Webinar and/or In-person C&TC Training
Host a Standard In-person C&TC Training at my site
Attend a Custom C&TC Training
Send staff to a Custom C&TC training
Host a Custom C&TC training at my site