Training Request Form

This form allows the Community Health Education and Resiliency Program to take and keep track of training requests. Please complete the form in its entirety. If you have any questions, please feel free to contact:

Savannah Gene, Program Director (She/Her/Hers) sgene@aaihb.org
Kurt Begaye, Senior Capacity Building Specialist (He/Him/His) kbegaye@aaihb.org

Name(Required)

First Last

Title(Required)

Organization(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Work Phone

Mobile Phone

Training Topic (one topic per request)(Required)

Please specify desired outcomes, target audience, and/or custom topic request:(Required)

Training Location(Required)

Equipment / Tech Availability(Required)

WiFi/Internet Available

AV Equipment Available

Expected Number of Participants(Required)

Requested Date(Required)

CAPTCHA

Program/Grant	Funding Source	Project Period End Date
Native American Research Center for Health	NIH	7/2022
AI Suicide Prevention Resource Guide	CYFD	6/2021
AI Suicide Prevention Strategic Planning Sessions	DOH	6/2021

Training Request Form

Contact information

7001 Prospect Pl. NE
Albuquerque, NM 87110

Ph: (505) 764-0036
Fax: (505) 764-0446
Toll Free: 1-800-658-6717

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