Fillable 4C App YEAR 2 (California State University, Fresno)

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4C App YEAR 2 (California State University, Fresno)

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  • 27 check-boxes
  • 49 other fields

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File type: PDF

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This project is funded by the Mental Health Services Act (MHSA) in partnership with the California Department of Mental
Health and Department of Developmental Services.
Funded by:
APPLICATION
ENHANCING CULTURAL COMPETENCE IN CLINICAL CARE SETTINGS
(4C Project)
COHORT 2: January – November 2016
1. PERSONAL INFORMATION:
Last Name:
First Name:
Street Address (Home):
City:
County:
State:
Zip:
Phone:
E-mail:
Male
Female
2. PRIMARY EMPLOYER/ORGANIZATION:
Agency Name:
Job Title:
Street Address:
City:
County:
State:
Zip:
Direct Phone:
Cell Phone:
3. ETHNICITY:
American Indian or Alaskan Native
Caucasian
Asian (Specify Ethnicity):
Mixed Heritage
Black or African-American
Hispanic or Latino
Other (Please Specify):
4. LANGUAGES OTHER THAN ENGLISH SPOKEN FLUENTLY:
Spanish
Hmong
Other (Please Specify):
5. EDUCATION:
Degree (s) and Certificates
Major
Date Completed
(mm/yyyy)
Currently a Student?
Y/N
6. PROFESSIONAL LICENSE (s):
Type of License:
Intern/License #:
Year Licensed:
This project is funded by the Mental Health Services Act (MHSA) in partnership with the California Department of Mental
Health and Department of Developmental Services.
Funded by:
7. YEARS WORKING WITH CHILDREN UNDER 5:
0 – 2 Years
3 – 5 Years
5 – 10 Years
Over 10 Years
8. ARE YOU CURRENTLY WORKING DIRECTLY WITH CHILDREN UNDER 5:
Yes
No
If not, please indicate current profession:
9. WHAT COUNTIES DO YOU SERVE IN YOUR WORK?
(CHECK ALL THAT APPLY):
Fresno
Kings
Madera
Mariposa
Merced
Tulare
Other (Please Specify):
10. ARE YOU INTERESTED IN OBTAINING CONTINUING EDUCATION UNITS
(CEU’s):
Yes
No
If yes, specify type of CEU’s and LICENSE #:
Marriage and Family Therapy
Social Work
Nursing
Attendance at ALL sessions is expected. Participants with three or more unexcused absences
will NOT receive a certificate of completion at the end of the training
series.
A NON-REFUNDABLE REGISTRATION FEE OF $95, AND AN ADDITIONAL FEE OF $25 FOR CEU
CREDITS, WILL BE DUE UPON ACCEPTANCE TO THE PROGRAM.
Signature Date
Submitting your completed application does not guarantee acceptance into the program. Your application will be
reviewed and you will be notified via e-mail if you have been accepted by Friday, December 4, 2015. Registration
and CEU (if applicable) fees are not required until you receive notification of acceptance.
IMPORTANT:
Please fax or e-mail your completed application to Wendy Davis at wdavis@csufresno.edu or
559-228-2168 by Monday, November 30, 2015. Please make a copy of your completed
application for your records before submission.
For additional information contact Wendy Davis at (559) 228-8727.
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4C App YEAR 2 (California State University, Fresno)

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Completed 16 July 2020

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