Select Your Class:
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E1223, Tue,Wed,Thu, 6-9pm, 11.07-12.07.23
W1223, M-F, 9a-6p, 12.11-12.15.23
Name
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First Name
Last Name
MAILING Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Email
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example@example.com
Please Select Your Gender Identity
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Male
Female
Transgender Male
Transgender Female
Non-Binary
Prefer to not answer
Who is the consumer in recovery? Please select all that apply:
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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:
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Drug Misuse
Mental Illness
Trauma
Criminal History
Are you currently employed as a peer support professional in your community?
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YES
NO
How do you see yourself using your lived experience to support others in the journey?
*
Signature
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Clear
How will this training support your recovery and opportunities to contribute to your area's recovery
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Date
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Month
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Day
Year
Date
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