2021 Train the Trainer Registration

Train the Trainer
Name*

First NameLast Name
Please select Your Class:

Rescheduled: Jan 9th & 10th (Dec 8th & 9th), 9am-5pm; M/TFebruary 6th & 7th, 9am-5pm; M/TMay 9th & 10th, 9am-5pm; T/W - RESCHEDULED April 6TH & 7THJune 19th & 20th, 9am-5pm; M/TAugust 17th & 18th, 9am-5pm; H/FOctober 19th & 20th, 9am-5pm; H/FDecember 7th & 8th, 9am-5pm; H/F
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I have successfully completed State Approved Peer Support Professional Training.*

YesNoType option 3Type option 4
I am currently employed as a Peer Support Professional.*

YesNoType option 3
Employer Business Name*
Direct Supervisor Name & Title*
Employer's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please select your target training area:*

JuneauAnchorageMat-SuFairbanks
Your Work Email
example@example.com
Your Work Phone Number
Please enter a valid phone number.
It is essential that you understand the limitations attached to this training. Please read and initial each of the following:
I understand that this training only allows me to offer Alaska Behavioral Health's State-Approved Peer Support Training at and within my Place of Employment and nowhere else.*
Please initial you understand the above statement
If/when my tenure at my Place of Employment ends, so does my ability to train Peer Support Professionals using Alaska Behavioral Health's State Approved Peer Support Training Curriculum. Furthermore, it is my responsibility to notify AKBH's PSP Training Program of my departure, so they can update my status at DBH's list of sub trainers.*
Please initial you understand the above statement
I will not charge a cost for any Peer Support Professional Trainings held at my Place of Employment*
Please initial you understand the above statement
I will provide AKBH with a list of all trained peer support professionals as well as a photo copy of all Certificates of Completion within fourteen (14) days of class completion.*
Please initial you understand the above statement
I cannot alter the contents of AKBH's PSP Training Curriculum as it is written and approved by the State of Alaska Department of Behavioral Health. I can ADD subsections specific to recovery services provided by my Place of Employment.*
Please initial you understand the above statement
I understand that my ability to train peer support professionals is limited to incoming and consumers actively utilizing recovery services at my Place of Employment; No public trainings beyond my Place of Employment.*
Please initial you understand the above statement
This training only qualifies me to train individuals interested in becoming Peer Support Professionals, and NOT additional PSP Trainers.
Please initial you understand the above statement
As a Certified Peer Support Trainer using AKBHs PSP Training Curriculum, I agree to attend quarterly meetings to learn of any changes to the curriculum, expand my skills as a trainer, and maintain compliance as addressed by the State of Alaska DBH and AKBHs agreement to allow my Place of Employment to facilitate their Peer Support Professional Training.*
Please initial you understand the above statement
By signing below, I (insert full name), working with (Employer Name), understand and agree to adhere to the expectations set forth as a formally Certified Peer Support Trainer in partnership with Alaska Behavioral Health.*
Please give your Full Name, and Your Employer's Name
Signature*

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Date*

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