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SBIRT Training: Organization (Group) RSVP

??day, April ??th, ?:00am - ?:00pm

@San Francisco Community Clinic Consortium

2720 Taylor Street, Suite 430

*The names of first 3 participants submitted for your organization will be registered and any additional names will be placed on a waiting list to be notified about two weeks prior to the training.

** Continuing education credit choices include: CME (applies to physicians, nurse practitioners, and physician assistants), PSY, RN, MFT, LCSW, CADC, CATC, CAS, and RAS.

***License number is required for participants wishing to receive CME, PSY, and RN credits/ contact hours.

Contact Name *
Contact Name
Mailing Address *
Mailing Address
Phone *
Phone
Participant 1 (P1): Name
Participant 1 (P1): Name
P1: Phone Number
P1: Phone Number
Participant 2 (P2): Name
Participant 2 (P2): Name
P2: Phone Number
P2: Phone Number
Participant 3 (P3): Name
Participant 3 (P3): Name
P3: Email Address
P3: Email Address
P3: Phone Number
P3: Phone Number
*Participant 4 (P4): Name
*Participant 4 (P4): Name
to be put on waiting list
P4: Phone Number
P4: Phone Number
*Participant 5 (P5): Name
*Participant 5 (P5): Name
to be put on waiting list
P5: Phone Number
P5: Phone Number