Name: 

Site Name: 

Site Number: 

Have you scheduled or taught your first class?

Yes No

What class option are you teaching?

Safe Sitter (2 day) Basic Both

Do you have any comments you would like to share?  (About the workshop; instructor issues; comments about teaching; curriculum etc.)

Would you like a follow-up phone call?

Yes No

If yes, what is the best time and phone number to reach you?