Medication Assistance Trainer Registration Form
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Trainer Medication Assistance Training Registration Form
Phone # (required):
How would you classify yourself:
I am an independent provider
I work for an organization
Name of organization, if applicable:
City & Date of Class:
Casper on 4/16/14 & 4/17/14
Casper on 8/20/14 & 8/21/14
Check the training schedule for location and time of trainings. Schedule and Locations of Trainings are subject to change.
Verify all fields are complete before you submit. If a form is missing information it will not be accepted and you will not be enrolled in the class.
DO NOT register for a class that is FULL or has been CANCELLED.
Are you an active Trainer re-certifying?
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