CAI - HRSA - Peers Advocates as Essential Members of Multi-disciplinary Healthcare Teams

Technical Assistance

Available to Participants

Pre-Registration Application
Click here for the pre-registration form in pdf format
that you can print, complete and submit via mail or fax.

FAX your completed registration form to:
(212) 629-3321
attn: Mirriam Grill

MAIL your completed registration form to:
attn: Mirriam Grill
Cicatelli Associates Inc.
505 Eighth Avenue, 16th floor
New York, NY 10018

-or-

Complete the information below and submit the
pre-registration application online.
To be completed by authorized supervisor or executive director.

Your Name
Position
Agency
Address
City, State Zip
Telephone
Fax
Email

What Type of Ryan White Care Act Funds does your agency receive?
(Select) Title A:
Title B:
Title C:
Title D:
Contract #:

How long has your agency had a peer advocacy program?
If not yet, when are you planning on implementing a peer advocacy program?

Names of the Peer Advocates you plan on sending to this program:
1st:
2nd:

Name of the Peer Supervisor and Clinic Manager who will attend this program:
Peer Supervisor:
Clinical Manager: (Recommended)

After you have completed the information
hit the submit button.

You will be contacted by CAI project staff
upon review of the pre-registration application.

Cicatelli Associates Incorporated, 505 Eighth Avenue, Suite 1600, New York, NY 10018
phone: (212) 594-7741 / fax: (212) 629-3321
http://www.cicatelli.org

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