Intensive & Practicum Training Application

Contact Information: Organizer (Materials will be shipped to this address)

First Name *

Last Name *

Middle Initial:

Closed Training Agency or School

Street Address *

City *

State *

Zip Code

Country *

Preferred Phone Number *

Type

Email Address *

Training *

Open Training

Closed Training

Level *

Length *

3 consecutive days (24 hours)

4 days (27 hours)

Location: *

Dates: *

Estimated # Particpants:

Basic:

Advanced:

NBCC Requirements

Only instructors with credentials of a master's or higher can teach courses leading to NBCC credit. If you do not have these credentials, you may teach but cannot offer NBCC credit. All promotional material must state your credentials.

*

I have a master's or higher in a helping profession.

I am an NCC.

I do not have a master's or higher and understand that although I may teach, I cannot offer NBCC credit.

Practicum Supervisor (if training is closed and has 17-20 participants):

Credentials:

Basic Instructor:

Instructor 2:

Credentials: *

Advanced Instructor:

Instructor 2:

Credentials: *

Basic Practicum Instructor:

Instructor 2:

Advanced Practicum Instructor:

Basic Practicum Instructor:

Instructor 2:

Options for open 4 day trainings and 27 hours, check one:

4 Consecutive Days

Two Days over 2 weekends

Evening sessions over 2 months

4 one-day a week sessions

4 one-days over 1 month

4 Professional Development Days in the same school year

Options for 3 days and 24 hours, check one:

3 consecutive days, only option

Agreement: I will follow what is outlined in the WGI Policies and Procedures Manual (ppm), and am aware of current acceptable Intensive Training format and their terms.

Signature of Organizer

clear

Date:

Please sign (to the best of your ability) in the above box using your mouse. Once you click on submit you will receive an email of this form for your records. Please foward to the Regional Board Member for approval.