Course Registration Form

Student Registration Form

Please fill out all information on the form below:
Student Name- The way it will appear on your certificate:

First NameMiddle NameLast Name
The Name you wish to be called:
Birth Date

MonthDayYear
Gender
Student E-mail
example@example.com
Mobile Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Favorite Color:
Favorite Animal:
Please share your recovery story - including how much time you have been in long-term recovery (your recovery may be in regards to any stuggle you have overcome):
Please share any recovery work or volunteer experience you have:
Please share any certifications, licenses, or credentials you have including your highest level of education:
Please share why you would like to be one of the ten participants chosen to participate in this program?
This certification program requires up to possibly 9 hours a week of particpation (this includes a 3-hour class only on the designated Monday nights AND up to 1 hour daily of required reading and study. Are you in a positon to make this committment?

YESNO
Please list any physical, social, or emotional limitations you may have so that we may respect those in order to make your experience seamless.
Please share any spiritual beliefs/philosophies you may have (this helps us to be sensitive to respecting your beliefs)
Signature

Clear
Should be Empty:

Student Registration Form