CRITICAL INCIDENT STRESSMANAGEMENTINDIVIDUAL CRISIS AND PEERSUPPORTREGISTRATION FORM

July 21 and 22, 2009Sunset Ave. Church of Christ, 600 OrchardAve.Madera, CA 93637

NAME: ADDRESS:CITY:STATE: ZIP:EMAIL: PHONE NUMBER(S):PROFESSION:AGENCY REPRESENTING:HAVE YOU BEEN TO CISM TRAINING BEFORE: Y NIF YES, WHICH COURSES:Cost of the course is $125. Payment needs to be receivedone week in advance of the training, unless specialarrangements have been made. You may send this form inmy email and mail the check separately, to reserve a spot,or you may send them together to:Central Valley CISM Training