Free Free In-service or Educational Training Request - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-22553A (07/2008)

STATE OF WISCONSIN

FREE IN-SERVICE OR EDUCATIONAL TRAINING REQUEST
The Office for the Deaf and Hard of Hearing provides free in-services / presentations / trainings to other organizations, agencies, and businesses that seek to improve their understanding of issues relating to deaf, hard of hearing, deaf / blind or have a hearing loss. Completion of this form is voluntary. Personally identifiable information collected on this form will be used only to schedule in-service or educational training as requested. Complete and either mail to ODHH, Box 7852, Madison, WI 53707 or Fax to (608) 266-3256. Requestor Name Title Organization Street Telephone Fax E-Mail

City / Town, State, Zip Code

Training Event Information (Require a minimum of three (3) week's advance notice)
Name of Event

Type of Event

Purpose of Event

Date of Event Length of Event Target Audience (Check one) AODA Corrections Educational Employer Estimated Size of Audience Location of Event Room Number Street Address City State Law Enforcement Legal / Law Medical Mental Health

Time of Event

Professional Senior Citizens Youth Other -

Zip