Select Your Class:
*
Please Select
E0223, Tue,Wed,Thu, 6-9pm, 1.03-2.02.23
S0323, Sat, 9a-6p, 2.04-3.04.23
W0223, M-F, 9a-6p, 2.13-2.17.23
E0323, Tue,Wed,Thu, 6-9pm, 2.28-3.30.23
S0523, Sat, 9a-6p, 4.08-5.06.23
W0423, M-F, 9a-6p, 4.17-4.21.23
E0623, Tue,Wed,Thu, 6-9pm, 5.02-6.01.23
S0723, Sat, 9a-6p, 6.17-7.15.23
W0623, M-F, 9a-6p, 6.12-7.16.23
Name
*
First Name
Last Name
MAILING Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Please Select Your Gender Identity
*
Please Select
Male
Female
Transgender Male
Transgender Female
Non-Binary
Prefer to not answer
Who is the consumer in recovery? Please select all that apply:
*
I am the person in recovery
I am a family member of the person in recovery
What is the person in recovery from (yourself or the family member)? Please select all that apply:
*
Drug Misuse
Mental Illness
Trauma
Criminal History
Are you currently employed as a peer support professional in your community?
*
YES
NO
How do you see yourself using your lived experience to support others in the journey?
*
Signature
*
Clear
How will this training support your recovery and opportunities to contribute to your area's recovery
*
Date
*
-
Month
-
Day
Year
Date
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