CCD of Texas Chapter Request Form

Completing this form is the first step in having a CCDOT Chemical Dependency Recovery Chapter hosted in your facility. Please enter all data and return to the CCDOT office. 

Name of Organization:                                                                                          

Address:                                                                                                              

Desired Start Date for First Chapter Class:                                                            

Chapter Class Day of Week:                                                                                              

Chapter Class Start Time:                                                                                                

(Classes are usually 1.5 hours) 

Contact Person:                                                                                                 

Phone Number:                                                                                                  

Email Address:                                                                                                     

Name(s) of Teacher:                                                                                           

(Teachers shall attend a Chapter Orientation and Training Class prior to teaching the CCDOT Program.) 

Estimated Number of Students:                                                                             

Comments:                                                                                                        

                                                                                                                         

                                                                                                                         

                                                                                                                           

 

                                                                                                                         

Requestor's Signature                                                      Date

Return to: CCD of Texas, Mesquite, Texas

SetFree@CCDofTexas.org                      www.CCDofTexas.org