Participating Staff Please use the table below to provide the name, title, email address, and phone number for all three staff members identified to participate in the provider workshops. Staffing Name Position/Title Email Phone Level Leadership Supervisor Practitioner Commitment to Participate By signing we commit to attend all four provider workshops, which will take place at the DCF Professional Center (30 Van Dyke Avenue, New Brunswick, NJ 08901) on October 27, 2016; January 5, 2017; March 7, 2017; and May 9, 2017. __________________________ ________________________ ____________ Signature Leadership Printed Name Date – __________________________ ________________________ ____________ Signature EBP Supervisor Printed Name Date – __________________________ ________________________ ____________ Signature EBP Practitioner Printed Name Date –
Participating Staff Please use the table below to provide the name, title, email address, and phone number for all three staff members identified to participate in the provider workshops. Staffing Level Name Position/Title Email Phone Leadership Supervisor Practitioner Commitment to Participate By signing we commit to attend all four provider workshops, which will take place at the DCF Professional Center (30 Van Dyke Avenue, New Brunswick, NJ 08901) on October 27, 2016; January 5, 2017; March 7, 2017; and May 9, 2017. __________________________ ________________________ ____________ Signature – Leadership Printed Name Date __________________________ ________________________ ____________ Signature – EBP Supervisor Printed Name Date __________________________ ________________________ ____________ Signature – EBP Practitioner Printed Name Date
EBP_Blueprint_Provider_WorkshopApplicationForm.docx