Off-Site CHW or CHW/CRS Training Request Form (2014-2015)

Contact Person: ______Today’s Date: ______

Organization:______

Address:______

Phone: ______Email: ______Fax:______

Training Requested:___CHW Only___CHW/CRS

Do you have an identified trainer that has been certified through ASPIN? ___Yes ___No

Trainer Name (if applicable) ______

Proposed location of training: ______

Preferred Dates of Training (Note: Must allow a minimum of 60 days to complete all student applications/enrollment and finalize all details.

Date Preference #1 ______

Date Preference #2 ______

Approximately how many student candidates are you currently aware of who would apply for the training at your proposed location? ______

A minimum of 10 qualified students is required to host an off-site class (maximum of 20). Applicants must meet ASPIN’s standards to qualify for participation.

To meet/exceed that number would you be willing to open the class to persons from other communities? ___Yes ___No

Please mail, email, or fax this form to Kiara Bembry () :

8440 Woodfield Crossing Blvd., Ste. 460, Indianapolis, IN

Phone: 317-536-4684 Fax: 317-735-0019

Next Steps:

  1. ASPIN will review your request and preferred dates. You will be notified of the approved date.
  2. If you did not identify a trainer,ASPIN will supply you with a list of certified trainers. It will be your responsibility to contact them to gauge willingness and availability to train. You will contract with the trainer directly. The trainer will act as an independent contractor with your agency. His/her training fee will include at minimum: time, travel, expenses, manual duplication, evaluation duplication, supplemental training materials, preparation. It is suggested that the contract be written as tentative pending sufficient number of students in the class.
  3. Once the training is opened, ASPIN will accept student applications for that training. Prospective students must follow the application instructions found on the website: A $35 application fee is required for each applicant. Applicants are required to complete the application without assistance. Applications will not be processed until all required documents and fees are submitted. An organization may submit fees on behalf of all applicants if desired by agreement with the Program Coordinator.
  4. Once a minimum of 10 qualified applicants have been identified, ASPIN will contact you to confirm the training date and student roster. At this time, you may proceed with finalizing contracting details with the trainer and venue.
  5. All applicants will be notified of their status (accepted/not accepted) by ASPIN within 10 days of scheduled start of course. Students will be provided with a user name and password for access to the course Learning Management System in order to complete the online pre-course and assignment prior to the beginning of the course. Individuals, who do not complete them, will not be allowed to access the classroom portion of the course.
  6. A payment of student testing fee ($150 per student) is required for each accepted student prior to the first day of class. This may be sent to ASPIN via certified check or money order. Students/organizations that do not forward the fee within required time limits should not be able to participate in the class and will not be certified.
  7. ASPIN reserves the right to drop in at any time during the course to ensure fidelity to the approved state training.
  8. At the end of the classroom training, ASPIN will respond to all testing questions and provide technical support for that process.

Address Questions to:

Kiara Bembry ()

8440 Woodfield Crossing Blvd., Ste. 460, Indianapolis, IN

Phone: 317-536-4684 Fax: 317-735-0019