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Please select the VALRC specialist you consulted:


Application date:

Your name:
Name of organization:
Primary contact person:
Phone:
Fax:
Email:

Workshop Title:
Date(s):
Times/Hours (please be specific, such as 10 a.m.-3 p.m.) :

Location:
Name of site/Building:
Street Address:
City:
State:
Zip:

Targeted Audience:
Estimated # of Participants:
Maximum Room Capacity:
Name of Registrar:
Registrar Phone:
Registrar Email:
Open to Others?:


Please provide the following information as well, for all workshops.
What is the purpose of the workshops? Note: workshops must be for professional development/training purposes. Staff meetings, including those with a training component, will not be approved.



Typically, the VALRC staff will complete the information below for you. However, if you will be providing your own facilitator, please complete all fields below.
Facilitator Name:
Home Address:
City:
State:
Zip Code:
Phone (Home):
Phone (Business):
Email:
Fax:

Please notify the VALRC staff if any workshop information changes. This includes location, date, and cancellation.