Continuing Education Form

Continuing Education Form

Fill the form below accurately.
Provider's Name: *

First Name Middle Name Last Name
Phone Number: *

Area Code Phone Number
E-mail Address: *
Date

Month Day Year
Date
Which Video Did You Watch ? *
Choose From List
Name three things you learned from watching this video.
Please complete the submission form and include enough detail in your response to show that you watched the entire video and provide details of three facts you learned while watching it. Complete this form for each video you complete. This submission form will be submitted to the Management Team, at Acadia Care Group, who will ensure you get your CEU credit.
Electronic Signature
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Electronic Signature