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VCAT Course Application Form
PLEASE USE A SEPARATE APPLICATION FORM FOR EACH TRAINING

Name: (as you would like it to appear on your certificate)

Last 4 digit of your SS #:

Mailing Address:


City/State & Zip:

Agency Name:

Position:

Work Phone:

E-Mail Address:


COURSE TITLE

COURSE DATE

TOTAL FEE


   

Special accommodations you may require:

 

FOR OFFICE USE ONLY

Check # ________     Amt Recv’d $_________
Date recv'd_______Registration/Course Fee

Please mail your payment to VCAT, PO Box 1506, Burlington, VT 05402
FAX your registration to VCAT (802) 651-1573
Questions? Call Ola Williamson (802) 651-1572 or email: owilliamson@dataofri.org



The following information is requested in order to comply with grant funding requirements

Sex
___ Male
___  Female

 Race/Ethnic Origin
____African American
 ____ Native American Indian
____ Asian/Pacific Islander


____ Latino/Hispanic
_____Caucasian
_____Other

Your primary profession (check one only):

_____Counselor/Clinician
_____ Clinical Director/Supervisor
_____ Nurse

_____Psychologist
_____ Criminal Justice
_____ Program Coordinator

_____Program Director/Administration
_____ Student Assistance Counselor
_____ Mental Health Counselor
_____Other

Current Certifications or Licenses (check all that apply):

_____ CADC
______ LADC
______ Ph.D.
______ MA
______ Prevention Specialist

_____Social Work
_____ Nursing
_____ Psychology

_____Mental Health Counselor
_____ Other: __________



Your signature: ________________________________________________

VCAT is a collaborative effort of Southern New Hampshire University and the Drug and Alcohol Treatment Association of Rhode Island,
under grant from the Division of Alcohol & Drug Abuse Programs, Vermont Department of Health