The Training Request Form below is used to request training presentations from our staff. You may also download this form and fax your request to our Training Fax #: 215.599.5180.

Please note that the minimum number of attendees for a training is 10. If we arrive at a scheduled training and there are less than 10 participants, we will not be able to provide the training, but will offer to reschedule the training when more participants are available to attend.

  TRAINING INFORMATION  
Training Topic:*
Please select a training topic

Please provide 3 possible training dates

Proposed Date #1:*
Please enter first possible date for training

Proposed Date #2:*
Please enter second possible date for training

Proposed Date #3:*
Please enter third possible date for training

Training Start Time:
Invalid Input

Training End Time:
Invalid Input

# of Anticipated Attendees:*
Please select the expected # of attendees

Training Expectations:
Invalid Input

Audience Type:

Invalid Input


  REQUESTOR'S INFORMATION  
Please enter the requestor's information

First Name:*
Please enter requestor's first name

Last Name:*
Please enter requestor's last name

Title/Role:*
Please enter requestor's title or role

Agency/Organization:*
Please select the requestor's agency or organization

Email Address:*
Please enter requestor's email address

Phone:*
Please enter requestor's phone number

County:*
Please select your County


  TRAINING LOCATION INFORMATION  
Training County:*
Please select a training location county

Name of Contact Person at Training Location:*
Please enter name of the contact person at the training location

Address of Training Location:*
Please enter the training location address

Invalid Input

City:*
Please enter the city of the training location

State:*
Please enter the state of the training location

Zip:*
Please enter the zip code of the training location

Phone:*
Please enter the phone number of the training location

Type of Location:*
Please select the audience type

DISCLAIMER: Information and education provided by PCHC is intended as general information only and is not all inclusive or intended to replace physical, dental or behavioral health advice. If you believe that you, or someone you support, have physical, dental or behavioral health issues, please seek professional advice.