Scheduling a Provider Training

Register

We are excited to hear that you are scheduling a Be Active Kids provider training.  Please provide us with the following information about your upcoming training so that we can enter it into our database and ship you the kits needed for your training.

                            First Name
                            		This field contains the user's first name.
                            
                            *
                            
                            Last Name
                            		This field contains the user's last name.
                            
                            *
                            
                            Organization
                            		
                            *
                            
                            County
                            		
                            *
                            
                            Email
                            		A basic email field for collecting stuff like an email address.
                            
                            *
                            
                            Phone Number
                            		
                            Training Date
                            		
                            *
                            
                            Co-Trainer Name
                            		
                            Estimated number of participants
                            		
                            *
                            
                            Estimated number of centers/schools attending *
                            		
                            *
                            
                            Is this your first Be Active Kids provider training?
                            		
                            Additional Comments:
                            		
                            Order Id