Culturally Relevant and Affirming Care Training Application

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* 1. First Name

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* 2. Middle Name or Initial

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* 3. Last Name

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* 4. Home Address 1

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* 5. Home Address 2

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* 6. Home City

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* 7. Home State

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* 8. Home Zip

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* 9. Email

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* 10. Phone

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* 11. Employment Type

Employed full time (40 or more hours per week)

Employed part time (up to 39 hours per week)

Unemployed and currently looking for work

Unemployed and not currently looking for work

Student

Retired

Homemaker

Self-employed

Unable to work

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* 12. Would you like to be considered for tuition scholarship and engagement stipend?

Tuition Scholarship - If approved, your tuition $495 will be waived.

Tuition Scholarship & Engagement Stipend - If approved, your tuition will be waived, and you qualify to receive a stipend upon completion of all course requirements.

Neither - I would like to pay for my tuition for the course $495.