Personal Information - Children's Trust FAN Training January 2027

Training Application for Teams

Program Supervisors, please complete this application for your team.

* First Name:

* Last Name:

* Email Address:

Title/Role:

Agency Name:

* Program Name:

Agency Mailing Address:

Region (check all that apply):

This question is required.

Please share the following information for the additional members of your team who are interested in attending the training:

Staff Member Name:

Email Address:

Role:

Mailing Address:

Staff Member Name:

Email Address:

Role:

Mailing Address:

Staff Member Name:

Email Address:

Role:

Mailing Address:

Staff Member Name:

Email Address:

Role:

Mailing Address:

In a few sentences, please share why you and your team would like to participate in the FAN Training.

Does your agency serve families that are insured by MassHealth, even if your agency itself does not bill insurance?

This question is required.

Do you have additional staff who would be interested in attending this training if there are openings? If so, please list their names below.

This question is required.

I have read the Requirements for Training Participants
If selected to participate in the training, I agree that my team and I will participate in the virtual FAN training on Tuesday, January 12, 2027, Wednesday, January 13, 2027, and Thursday, January 14, 2027, and the virtual FAN Integration Training on Wednesday, June 2, 2027, if selected. My team and I have held these dates on our calendars.
As the supervisor for this team, I agree to participate in at least 10 of 12 FAN Monthly Mentoring Calls for Supervisors.