• 605-430-9361

MOON’S BRIDGE INSERVICE TRAINGING REQUEST FORM

Moon’s Bridge, Inc. will conducted In-Service Training as outlined below. The trainings will be conduct
in the San Luis, AZ community and/or at Moon’s Bridge unless other arrangements have been made and
both parties are in agreement.

all fields marked with an asterisk (*) are required

EDUCATIONAL TOPIC OF INTEREST

PLEASE place the number 1 / 2 / 3 in the order for which you are requesting a training.

STATEMENT OF ACCURACY FOR APPLICANT

I hereby affirm that all the above stated information provide by me is true and correct to the best
of my knowledge. I also consent that if chosen as a recipient of an In-Service Training, pictures
may be taken and used to promote Moon’s Bridge (MB) , Inc. OT educational programs.
I hereby understand I will not submit this application without all required attachments and
supporting documentation. Incomplete applications or applications that do not meet the criteria
with not be considered for this program.

CHECKLIST___APPLICATION ___ORDER OF REQUEST FOR TRAINING ___ CONTACT PERSON
INFORMATION

MAIL COMPLETE APPLICATION PACKAGE TO MOON’S BRIDGE, INC
C/O MONIKA SHUMBO-POISSANT, OTD, OTR/L, ATRIC
3958 SOUTH DEVANE DRIVE – YUMA, AZ – 85365
Cell Phone 605-430-9361 / Email – Moon@moonsbridge.com

There is no deadline for this application to be received by Moon’s Bridge, Inc. office. Trainings are ongoing based on the need of
the community, as well as the availability of an OTD to conduct the in-service training. All trainings will be conducted within the
San Luis, AZ community / Moons Bridge and/or at an agreed upon location. This may be include a local school site, the public
library and/or another location which is mutually agreed upon. NOTATION – ALL TRAININGS are conducted in the English

language.

The printed material will be provided in English.