TAC Train the Trainer Application

This is a registration form for a TAC Train the Trainer Event

Last Name(Required)

First Name(Required)

Credentials(Required)

Title(Required)

Highest Degree Earned and Year(Required)

License Held/State of Issuance/Renewal Date(Required)

Please list any current professional licenses with state of issuance and the date of renewal next to each.

Organization(Required)

Organization 2 (If applies)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Enter Email Confirm Email

TAC Site/Affiliation(Required)

List here the TAC site you would be training for.

Have you completed TAC Training?(Required)

Yes

When and where did you complete TAC Training?(Required)

List any additional professional certifications.

Clinical Experience:(Required)

Trainer Experience:(Required)

Professional Experience in Adoption Field:(Required)

Any personal connection with adoption? (Please mark all that apply)

No Personal Connection

Close family member/friend is adopted

Close family member/friend has adopted a child

Adoptive Parent

Adopted Person

Sibling of person adopted

Other connection

We value the importance of diversity and this information helps us understand the demographic makeup of our TAC Trainers.

Number of years working with families and children:

Race/Ethnicity

Gender

Please upload a resume or CV here.

Max. file size: 100 MB.

NOTE: if your resume or CV exceeds 100MB, please email your file to wright@adoptionsupport.org.