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2. HMIS Training Dates*
   -- Select One --Thursday 12/7/23 9am-11:30amWednesday 12/13/23 2pm-4:30pmWednesday 1/3/24 2pm-4:30pmThursday 1/18/24 9am-11:30amWednesday 1/31/24 2pm-4:30pmThursday 2/15/24 9am-11:30amWednesday 2/28/24 2pm-4:30pmThursday 3/14/24 9am-11:30amWednesday 3/27/24 2pm-4:30pm
4. Agency*
   -- Select One --Avalon HousingCatholic Social Services (CSS)HAWCIHN at Alpha HouseMichigan Ability Partners (MAP)Ozone HouseProject Outreach Team (PORT)Shelter Association of Washtenaw (SAWC)SOS Community ServicesThe Salvation Army
6. HMIS Agency Administrator*
   Enter First and Last Name (person submitting the training request)
8. HMIS Agency Administrator's Email*
9. HMIS Agency Administrator's Phone Number*
11. New User's First Name*
12. New User's Last Name*
14. New User's Email Address*
15. New User's Phone Number*
17. New User's Job Title*
19. ServicePoint Access Level*
    -- Select One --Agency StaffAgency AdministratorCase Manager ICase Manager IICase Manager III
20. New User Agency Role *
    -- Select One --EmployeeInternVolunteer
22. Enter Data As (EDA) Provider Identification Numbers*
    Enter the provider page ID numbers for the programs that the new user needs access to separated by a semicolon. For example, 7082; 9062; 1234
24. Has the user passed the initial MCAH Privacy and Confidentiality questionnaire?*

    1. Yes
    2. No
26. Comments / Questions for HMIS System Administrator
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field