Area 12 > Area 12 Training Registration

Your Contact Information

Please fill in all of the information below:

* Denotes required Field

First Name: *
Last Name: *
Contact Telephone: (Including Area Code) *
Email Address: *
Address:
City:
State:
Zip:
What is your Service Category? *	*Category New Applicant Enrolled Independent Provider Enrolled Agency Owner Employee of an Agency Other/person receiving services, family members, guardian, advocates I Don't Know
If you selected Employee of an Agency from the list above, please enter your agency name:

Class Schedule and Registration

Please select the training classes that you would like to register for. You may register for more than one class.

If training accommodations (such as interpreter services or limited-English proficiency) are needed please contact the training coordinator before registering on-line so we may assist.

Once you have made your selection, Click on the "Send Form" button at the bottom of the page. You should receive an e-mail at the e-mail address you provided which confirms the receipt of your request.

You must print out the confirmation e-mail and bring it with you the day of the class.

**Class sizes are limited. Registration does not guarantee a seat in the class. The Area Office may withdraw any registration prior to a scheduled class. The registrant will be notified of their registration withdraw via the contact email address provided on the on-line registration form.

**Please send cancellation requests by e-mail to Vanessa_Carter@apd.state.fl.us As a courtesy to our Medicaid Waiver Providers we ask that cancellations are submitted as soon as possible to ensure open vacancies can be filled.