Community Partners in Care

First Name (required)

Last Name (required)

Professional Title

Organization

Address:

City, State, Zip

Telephone Number

Fax Number

Email

Is your organization/program participating in the Community Engagement and Planning (CEP) Intervention Group?
 Yes No

Will You Need: (check all that apply)
 Disabled parking.  Disabled seating Vegetarian lunch

What continuing education credits will you request?
 Board of Behavioral Sciences (BBS) Continuing Education Units (CEUs) for Nursing CME no CEU request

Clinical degree or license type: (if applicable)
 MD/DO PhD/PsyD RN/BSN LCSW MFCC/ MFT MSW Certified Drug Counselor N/A

License Number (for CEU and CME applicants)