LEARNING CONTRACT PLEASE COMPLETE ALL REQUESTED INFORMATION 

TO ENSURE PROCESSING AND REGISTRATION 

PLEASE PRINT 

LAST NAME FIRST NAME 
AGENCY NAME AGENCY CODE 
(SEE BACK OF THIS FORM FOR LIST OF AGENCY CODES) 

AGENCY ADDRESS 

CITY STATE ZIP CODE 
( ) ( ) 
HOME PHONE BUSINESS PHONE 

E-MAIL ADDRESS 

DISABLED (CHECK ONE) GENDER (CHECK ONE) 
..YES ..NO ..M ..F 

HIGHEST DEGREE COMPLETED (CIRCLE ONE)
HS GED AA LPN RN BA/S MA/S/W PH/MD


I WILL BE APPLYING FOR CEU’S WITH: 
(SEE THE CERTIFICATION SECTION OF THE DSAMH TRAINING
CATALOG FOR DETAILS)


. CEAP . DBN . DCB . DPA 
. NAADAC . NBCC . NCGC 

..PHYSICAL THERAPY 
I understand that I should receive a confirmation of admission to 
a workshop before I attend. IF I AM NOT ABLE to attend a 
workshop, I will notify the Training Office at least 4 days in 
advance. I understand that all NO-SHOWS (someone who was 
admitted into a workshop, did not attend, and did not alert the 
Training Office) will be reported to my Program Director on a 
monthly basis. 

POSITION: 
PLEASE CHECK THE ONE THAT BEST DESCRIBES YOU: 
. Administrator/Manager . Physician/P.A.
. Case Manager/Counselor/Therapist . Prevention Worker
. Clinical Supervisor . Psychologist
. Consumer/Client . Social Worker
. Educator/Teacher/Instructor . Student
. Nurse . Support Staff
. Other . Volunteer


ETHNICITY: (CIRCLE ONE)
Alaskan Native Asian American African American Caucasian
Hispanic Native American Pacific Islander Other ____________


BY SUBMITTING THIS CONTRACT, 
YOU AGREE THAT YOU HAVE MADE 
YOUR SUPERVISOR AWARE OF YOUR 
REQUEST FOR REGISTRATION TO THE 
LISTED WORKSHOPS. 

WORKSHOPS REQUESTED 

1) 

WORKSHOP NUMBER DATE 

LOCATION 

WORKSHOP TITLE HOW DO YOU MEET THE PREREQUISITE? (IF APPLICABLE) 
2) 
WORKSHOP NUMBER DATE 

LOCATION 

WORKSHOP TITLE HOW DO YOU MEET THE PREREQUISITE? (IF APPLICABLE) 

3)


WORKSHOP NUMBER DATE 

LOCATION 

WORKSHOP TITLE HOW DO YOU MEET THE PREREQUISITE? (IF APPLICABLE) 
4) 
WORKSHOP NUMBER DATE 

LOCATION 

WORKSHOP TITLE HOW DO YOU MEET THE PREREQUISITE? (IF APPLICABLE) 

Mail or FAX the completed Learning Contract to: HAVE QUESTIONS? 

DSAMH Training Office For further information, call (302) 255-9480 

Springer Building, 1901 N. Dupont Highway or e-mail us at DSAMH.training@state.de.us 
New Castle, DE 19720 
Fax: (302) 255-4450 


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