Enrollment Form: Learning Lab

Please complete this form to the best of your ability. All information is confidential and secure. Each field that contains an asterisk (*) must be filled out. If you are unsure about an answer, simply type "N/A" and move onto the next question. For payment information, see "Training Dates"

Thank you for your interest, we look forward to serving you!

Organization Name: *

Organization Type: *

Training Dates: *

Dates of your Learning Lab

Address: *

Address 2:

Apartment, Unit, or Suite #

City: *

State: *

ZIP: *

Your First Name: *

Your Last Name: *

Your Position Title: *

Will you be the only staff person from your organization attending the Learning Lab?: *

Yes

If no, please provide the name, title, and contact information for the other person(s) who will also be attending the Learning Lab:

Your Preferred Phone:

Your Phone: *

Best phone number to contact you

Your Preferred Email:

Your Email: *

Best email address to contact you

Fax:

Website:

Mission: *

Description of programs or services offered: *

Are there any specific organizational/programmatic needs Coming of Age can help you address?:

How did you hear about us?: *

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Other:

Additional Information & Comments:

Is there anything else you'd like to tell us about yourself or your organization that you did not get to mention above?

Non-Discrimination Policy Agreement: *

I acknowledge that my organization is in compliance with the Non-Discrimination Policy listed below.

Non-Discrimination Policy: Overview

No Coming of Age non-profit partner, or station, will discriminate against volunteers, or in the operation of its programs, on the basis of race; color; national origin, including limited English proficiency; sex; age; political affiliation; religion; or on the basis of disability if the volunteer is a qualified individual with a disability.

Reasonable Accommodations Policy Agreement: *

I acknowledge that my organization is in compliance with the Reasonable Accommodations Policy listed below.

Reasonable Accommodations Policy: Overview

Every Coming of Age non-profit partner, or station, will provide reasonable accommodation for persons with disabilities (including those with mobility, hearing, vision, mental and cognitive impairments, or addictions and diseases) to participate in programs and activities.

Signature: *

Checking this box provides a virtual signature that all of the above information is true and accurate to the best of my knowledge.

Signature Date: *

mm/dd/yyyy

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