Name (Executive Director or Administrator)
(Required)
First
Last
Name of contact person
(Required)
Agency
(Required)
Email
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone number
(Required)
Date of desired training session
This field is optional
MM slash DD slash YYYY
Time of desired training session
This field is optional
Hours
:
Minutes
AM
PM
AM/PM
Select the training session you would like to host
(Required)
Passenger Assistance Training (PAT) - Full Day
Defensive Driving
Accessible Lift & Securement (Half Day)
CPR
Disability Awareness
How many attendees from your agency will be in attendance
(Required)
Up to 8 attendees from host agency allowed
Please enter a number less than or equal to
8
.
Do you have an accessible vehicle available for the training session?
(Required)
Accessible vehicles are only required for hands-on training sessions. Please state whether you have more than one vehicle available.
Does your agency have access to Audio Visual equipment?
(Required)
Yes
No
Can you accommodate up to ten people?
(Required)
Yes
No
Anything else we should know, if yes please describe below?