Prevent Child Abuse ArizonaLaw Enforcement ApplicationPage 1 of 2

LAW ENFORCEMENT APPLICATION

December 8- 12, 2014 • Black Canyon Conference Center • Application deadline: October 31, 2014

February 9-13, 2015 • Black Canyon Conference Center • Application deadline: December 29, 2014

Please Print

Name Title

AgencyDept/Division/Unit

AddressCityZip

Phone Fax

Email

Do you work at an Advocacy Center? (Circle one) Yes or No

DO NOT SEND FUNDS WITH THIS APPLICATION

Registration fee will be due upon written acceptance and invoice

Registration Fee: $100.00 for each participant

Please mail or fax application to:

Prevent Child Abuse Arizona • PO Box 26495, Prescott Valley, AZ 86312 • 928.445.5038 • 928.778.5300 fax

Questions or cancellations contact: Claire Louge ()

Please initial & complete all sections. INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED.

I have attended a Basic Interviewing Course within 2 years of this training. Date attended

I agree to attend and participate in the entire 40-hour course.

I have conducted and/or observed six (6) interviews of children to include: two (2) preschool, two (2) school age, two (2) mentally challenged. (required prior to attending this training)

I have investigated (beyond first responder) child sexual abuse/child physical cases in the past 12 months out of _____ cases in my jurisdiction.

I am not currently assigned to sex/family crimes but I will be transferred to this assignment on ______.

Percent of total case load involving interviewing children is .

Number of people in your department, currently working child crimes, who have previously attended this training:

Please check this box only if you want a Spanish interviewee.

Approval of supervisor

Supervisor’s signature(required)Date

Print Supervisor’s Name Phone Email

AZPOST Approval: 40 hours

Confirmation and invoice will be sent via email 5 weeks prior to training