DV Initiative Participation Form — Alabama Chapter of the American Academy of Pediatrics

Domestic Violence Initiative
Local Team participation form

Thank you for agreeing to work on supporting children who are affected by domestic violence. You are agreeing to:

Attend our three webinars - April 7, first week of May (TBA), first week of June (TBA) - they WILL all be recorded.
Communicate with your Domestic Violence counterpart, at a minimum, in your local community (the Chapter will assist in identifying this person through our relationship with the Alabama Campaign Against Domestic Violence) in between the webinars.
Share your thoughts/ideas with us on what you learned in your discussions so that we can develop a blueprint that can be replicated in other parts of the state.

Contact:
Linda P. Lee, APR, Executive Director
llee@alaap.org

Name

First Name

Last Name

Practice/Clinic/Organization

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Will you engage your staff as well?

Yes, clinical staff

Yes, referral coordinator

Yes, practice manager

Yes but unsure of who at the moment

Comments/Notes