Collaborating with Schools in Pediatric Primary Care Registration

Collaborating with Schools in Pediatric Primary Care
Registration Form

Please use the form below to register for an upcoming Collaborating with Schools program, where you'll learn evidence-based strategies to tap into school collaboration and better support children’s behavioral health needs.

Duration: One-day live course, followed by four (1-hour) group learning calls
Format: Virtual
Cost: $600

If the dates listed do not work for your schedule, please sign up to be notified of future training courses here.

This form is intended for registration of single participants. To register a group of participants, please email us at ppp@thereachinstitute.org

Program Information

Program

Please select the start and end dates of your chosen program.

Start Date

End Date

Contact Information

Salutation

First Name

Last Name

Participant Email

The participant's email address must be entered for registration. All program communications prior to, during, and after the program require responses from the participant directly.

Phone

Please provide your mailing address below. Mailing address is required in order to receive program materials.

Mailing Country

Mailing Street Address

Mailing State/Province

Mailing City

Mailing Zip/Postal Code

Professional Information

With which license do you practice?

List other/additional licenses

What is your discipline?

List other/additional discipline

What is your occupation?

Organization/Practice Name

Organization/Practice Country

Organization/Practice Street Address

Organization/Practice City

Organization/Practice State/Province

Organization/Practice Zip/Postal Code

Referral Information

How did you hear about this training? (select all that apply)

A friend/colleague told me about this trainingI saw a social media postI found it on Google/search engineMy employer told me about this trainingI heard about it from REACH (newsletter, email, call group,, etc.)I found out about it from a professional association/publication/conferenceOther

Name of referral:

Select Platform:

Name of Employer

Name of association/publication/conference:

Referral Source:

REACH does not sell or share any personal registration data.

Payment Information

Pre-Discount Total

Payment Amount

Promo Code (if applicable)

Discount Amount

Name on Card

Card Number

Code

Billing Email

Billing Country

Billing Street Address

Billing State/Province

Billing City

Billing Zip/Postal Code

Contact Information

Collaborating with Schools in Pediatric Primary Care Registration

Collaborating with Schools in Pediatric Primary Care Registration