If your clubhouse or agency is interested in sending a group to Clubhouse Training, feel free to print this form, complete it, and send it to Alliance House.
Application for
Please
print or type in black ink. Please mail to:
Colleague Training
Clubhouse/Agency Name
_______________________________________________
Clubhouse/Agency Address
_______________________________________________
_______________________________________________
________________________________________________
Telephone Number
____________________Fax_______________________________
E-mail
______________________________
Clubhouse
Director_________________ When and Where Trained?________________
Please check the Type of Training
requested:
____ First Time Clubhouse
Training (New Clubhouses) $4,800US. This includes the
Director, one staff member, one
clubhouse member, and a 3rd week
administrator.
____ Clubhouse Training
(Established Clubhouses) $4,000US. This includes one staff member, one clubhouse
member and a 3rd week
administrator.
Additional people for the entire
training period = $1,600US per person
Additional Administrators for the
last week of training = $625US per person
*The fee for training bases
providing the Two Week Pilot Training is the same as
above.
____ One week specialized track
fee $1,250US. This includes one staff member and one
clubhouse member. (Additional
participants are $800US per person)
____ Three day
Orientation/Overview Visit for two people $800US. (Additional
participants are $400US per
person)
Dates of Training requested: ____________________
Please list the names and
Clubhouse position (member/staff/director) of the people you
want to send for training:
Name:_____________________________________Position:_________________
Name:_____________________________________Position:_________________
Name:_____________________________________Position:_________________
Third week Administrator (second
week Administrator for Two Week Pilots) & position:
_____________________________________________________________________
Training reservations will be
confirmed when a completed application and a nonrefundable deposit of 50% of the
tuition is received. The non-refundable deposit is
applicable for the confirmed
dates only. Final payment is due ten days prior to arrival.
Post training site visits are
negotiable and are scheduled approximately six to nine
months after the training
experience. The training base and the clubhouse requesting a
post site visit will share in the
cost of the visit.
Clubhouse Director Signature:
_______________________ Date: __________________
Name of Auspice Agency (if
applicable)
Please list the name and
signature of the authorized representative of the Auspice Agency
Name:
_____________________________________
Signature:___________________________________
Date: ________________
Thank you for your application
and we will be in contact with you in the near future.
Please visit www.ICCD.org
for more information