Please fill out the form below to request new organizational membership in the Virginia Joint Training Coalition:

ORGANIZATION INFORMATION
Organization name: Date of Application:
Website Address:
Current Address:
City: State: ZIP: Phone:
Location of Operations by Area: (please check all that apply) Number of Employees by County
City of Alexandria
Arlington County
Fairfax-Falls Church
Loudoun County
Prince William County
Other:
INTEREST IN JOINING THE COALITION
(SELECT ALL THAT APPLY)
We are interested in joining the coalition for... We can contribute to the coalition in the following ways...
Networking opportunities
Access training opportunities and events±
Share resources
Expand personal training skills and abilities
Stay informed on regulatory issues 		Maintain the annual membership fee (Required)
Participate in monthly meetings
Open our training courses to other coalition members
Identify resources, guest speakers, etc.
Serve on committees
Serve as Subject Matter Experts on particular topics*
±Some agencies may charge participants for enrollment in certain classes like medication administration to help offset the costs associated with providing these trainings.

*Comments:

TRAINING COORDINATOR
Each organization must assign a Coordinator to receive invoices, update website, process certificates, etc.
Name:
Phone: FAX: Email:
HOW DID YOU HEAR ABOUT US?
Training Coalition Website
Search Engine (e.g. Google)
At an Event:
Reference (please specify):
ORGANIZATIONAL HISTORY AND DESCRIPTION OF SERVICES