Home - AHCI



left7112000right10541000right0Mental Health First AidMaterials and Meals Request Form020000Mental Health First AidMaterials and Meals Request FormAllegheny HealthChoices, Inc. (AHCI) supports a collaborative of Mental Health First Aid trainers in Southwestern Pennsylvania and is able to assist trainers in providing materials and/or meals for their Mental Health First Aid trainings. Please complete and submit this form to MHFA@ 30 days prior to your training.Requester Name: Click to typePhone Number: Click to typeright343535Training Information00Training InformationEmail: Click to typeTraining Date(s) and Time(s) (e.g., 1/1/2018, 8:00am to 12:00pm)Day 1:Click arrow to select dateTime: Click to typeto Click to typeDay 2:Click arrow to select dateTime: Click to typeto Click to typeAdult or Youth: Select from menuSpecialty Curriculum (if relevant): Select from menuEstimated Number of Participants: Click to typeName of Group/Organization to Be Trained: Click to typeOrganization Type: Select from menuDoes this organization primarily serve individuals who receive medical assistance or are medical assistance-eligible? Select from menuPrimary Audience: Select from menuOther (please specify): Click to typeTrainer Name: Click to typePhone Number: Click to typeEmail: Click to typeTrainer Name: Click to typePhone Number: Click to typeEmail: Click to type10795442614Section A: Materials Request020000Section A: Materials RequestPlease List Additional Trainers (if relevant): Click to type If you would like to request materials for your training, please complete this section. Otherwise, leave it blank. Number of Packets Needed: Click to typeNumber of Manuals Needed: Click to typePick-Up Date: Click arrow to select dateTime: Click to type5427279461010Continue to Next Page 00Continue to Next Page *Materials will be available for pick-up at least 1 week prior to your training at AHCI’s office, 444 Liberty Ave., Pittsburgh, PA 15222, typically between 8:00AM and 5:00PM Monday through Friday.10795483Section B: Meals Request020000Section B: Meals RequestREMINDER: THIS SECTION SHOULD ONLY BE COMPLETED IF THE HOST ORGANIZATION IS UNABLE TO PROVIDE FOOD AND FUNDING IS APPROVED FOR YOUR TRAINING.When organizing your training, first ask the host organization if they are able to offer food for their participants. If the host is unable, but you would still like to request food to be provided for your training, please complete this section. Otherwise leave it blank.If funding is approved to cover the cost of food for your training, AHCI will coordinate ordering and delivery using the information you provide. Half-day trainings can include coffee, water, and a light meal or snack items. Full-day trainings can include coffee, water, a light breakfast or snack items, and lunch. You as the requester, in addition to the on-site trainer contact, will receive a confirmation email after the order has been placed.If the number of attendees changes from what you provided on this form, you as the requester must contact the caterer with the final number at least 5 days prior to the training. The caterer’s information will be provided in the confirmation email you receive. 1079539558600If the training is cancelled for whatever reason, please contact MHFA@ as soon as possible.Estimated Number of Attendees (including trainers): Click to typeSite Address with Floor and Room Number: Click to type*This is where the food will be delivered. Please include the building name, floor, and room as relevant.Special Instructions: Click to type(e.g., park in rear; enter through the glass doors at the front; please call for gate code; no elevator available)Requested Delivery Time for Breakfast/Snack Items: Click to typeRequested Delivery Time for Lunch: Click to type*If you have a full-day training and wish to request both breakfast and lunch, please note the delivery times separately. On-Site Contact Name: Click to typeCell Phone Number: Click to typeEmail: Click to type*This is the on-site person that the caterer will contact for delivery and is typically one of the trainers.right369589FOR INTERNAL USE ONLY020000FOR INTERNAL USE ONLYFunder: Select from menuOther (please specify): Click to typeNumber of AHCI Trainers: Click to typeBilling: Select from menuNumber of Other Trainers: Click to typeNotes: Click to type ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download