Creating Lasting Family Connections Ohio Implementation Training Application s1

Creating Lasting Family Connections Ohio Implementation Training Application

Cincinnati Training

Through the UMADAOP of Mansfield, on behalf of the Federation, COPES, Inc. will provide a series of three 3-day (9 days total) trainings Creating Lasting Families Connections Original CLFC/Fatherhood for up to 20 individuals in Cincinnati. This training will be provided at no cost; however, by participating in this opportunity, you are agreeing to work in partnership with the UMADAOP Federation to fully participate in the entire training curriculum.

Cincinnati UMADAOP - Original CLFC/Fatherhood Training

Session 1 - October 31 - November 2, 2016

Session 2 - November 8-10, 2016

Session 3 - November 29 - December 1, 2016

The Children of Incarcerated Parents State Team and the UMADAOP of Mansfield staff will review these applications and we will notify those selected of their invitation to attend a CLFC Implementation training by October 14, 2016.

Name:
Job Title:
Phone:
Email:

Mailing Address:

Organization Name:

Type of organization (check all that apply):

¨  Behavioral Health Organization
¨  Integrated Delivery System
¨  Re-entry Coalition/Community Partner / ¨  Adult Correctional Facility
¨  Youth Correctional Facility
¨  Other (Please Specify.) ______

Are you currently implementing a program or curriculum?  Yes  No

If yes, please list program/curriculum and indicate if it is evidence-based. (Add additional rows if needed.)

Program/Curriculum Name / Is this program/curriculum evidence-based?
1. 
2. 
3. 
4. 
5. 

Please indicate the ages served by your agency/organization. (Select all that apply.)

¨  Birth to age 8
¨  Ages 9-17 / ¨  Ages 18-25
¨  Age 26 or older

How many times are you planning to implement each of the CLFC Programs in SFY2017?

Original CLFC times

CLFC Fatherhood Program times

(Continues on next page.)

This signed document, submitted by the deadline date of October 3, 2016, indicates your commitment to full participation in the CLFC training and your agreement and receive free RCH/CE hours and CLFC materials. Attendance at all trainings is mandatory in order to be a certified CLFC Facilitator.

______

Applicant Signature Date

______

Signature of Authorizing Agency Representative Date

For questions:

Benjamin Davis, Mansfield Regional Coordinator

567-307-7299 / Harim Ellis, Cincinnati Regional Coordinator

513-541-7099 EXT. 14

Please return completed application to: UMADAOP of Mansfield

P.O. Box 1315

400 Bowman Street

Mansfield, OH 44903

FAX: 419-525-3538