Fillable 4C Application YEAR 2

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4C Application YEAR 2

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The 4C Application YEAR 2 form is 3 pages long and contains:

  • 2 signatures
  • 36 check-boxes
  • 51 other fields

Country of origin: US
File type: PDF

U.S.A. forms for California State University, Fresno

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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:
Home Phone:
Gender:
Male
Female
2. PRIMARY EMPLOYER/ORGANIZATION:
Agency Name:
Job Title:
Street Address:
City:
County:
State:
Zip:
Work Phone:
Cell Phone:
3. AGENCY OR COUNTY TEAM:
Are you applying as part of an agency or county team? If yes, please indicate:
County Name:
OR
Agency Name:
4. HOW DID YOU HEAR ABOUT THIS TRAINING:
Prior 4C Participant (provide name):
Other (please specify):
5. ETHNICITY:
American Indian or Alaskan Native
Caucasian
Asian (Specify Ethnicity):
Mixed Heritage
Black or African-American
Hispanic or Latino
Other (Please Specify):
6. LANGUAGES OTHER THAN ENGLISH SPOKEN FLUENTLY:
Spanish
Hmong
Other (Please Specify):
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. EDUCATION:
Degree (s) and Certificates
Major
Date Completed
(mm/yyyy)
Currently a Student?
Y/N
8. PROFESSIONAL LICENSE(S):
Type of License:
Intern/License #:
Year Licensed:
9. YEARS WORKING WITH CHILDREN UNDER 5:
0 – 2 Years
3 – 5 Years
5 – 10 Years
Over 10 Years
10. ARE YOU CURRENTLY WORKING DIRECTLY WITH CHILDREN UNDER 5:
Yes
No
If not, please indicate current profession:
11. WHAT COUNTIES DO YOU SERVE IN YOUR WORK?
(CHECK ALL THAT APPLY):
Fresno
Kings
Madera
Mariposa
Merced
Tulare
Other (Please Specify):
12. PREVIOUS TRAINING:
Have you had any previous training in infant mental health or dyadic functioning?
Yes
No
If so, please specify type and location of training:
13. ARE YOU INTERESTED IN OBTAINING CONTINUING EDUCATION UNITS
(CEU’s):
Yes
No
If yes, specify type of CEUs:
Marriage and Family Therapy
Social Work
Nursing
**PLEASE SUBMIT A COPY OF YOUR RESUME ALONG WITH COMPLETED APPLICATION**
A NON-REFUNDABLE REGISTRATION FEE OF $95, AND AN ADDITIONAL FEE OF $25 FOR CEU
CREDITS, WILL BE DUE UPON ACCEPTANCE TO THE PROGRAM.
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:
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.
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 5 p.m. on Tuesday, November 10, 2015. Keep 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 Application YEAR 2

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Completed 19 May 2020

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