SU 24 Peer Recovery Support Specialist Certification Application

Participant Information

This application is for applying to the Governors State University Summer 24 RSS training. This training will only prepare students for NCPRSS certification through the Association for Addiction Professionals (NAADAC). Information regarding that certification can be found at https://www.naadac.org/ncprss.

Question Title

* 1. Contact Information

First Name

Last Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Preferred Name (if different from legal)

Personal Email Address

Phone Number

Question Title

* 2. Date of birth

MM/DD/YYYY Format

Date

Question Title

* 3. Are you a veteran of the U.S. Armed Forces?

Yes

Question Title

* 4. Are you a US citizen or are you authorized to work in the United States?

Yes

Question Title

* 5. What is your race?

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Prefer not to answer

None of the above

Some other race (please specify)

Question Title

* 6. Are you of Hispanic, Latino, or Spanish origin?

No, not of Hispanic, Latino, or Spanish origin

Yes, I am of Hispanic, Latino or Spanish origin

Prefer not to answer

Question Title

* 7. What is your Gender Identity?

Male

Female

Transgender

Nonbinary

Prefer not to answer

Other (please specify)

Question Title

* 8. What are your preferred pronouns?

He/Him/His

She/Her/Hers

They/Them/Theirs

Other (please specify)

Question Title

* 9. Are you or will you be the first person in your family to receive a college degree (Parents, grandparents, siblings do not have a college degree)?

Yes

Not applicable

Question Title

* 10. Are you currently employed?

Yes, employed full-time

Yes, employed part-time

No, currently not employed

Question Title

* 11. Do you speak additional languages?

Yes (please list)

Question Title

* 12. What is the highest grade or level of school you have completed or highest degree you have received?

Middle School or Junior High graduate

High School diploma or GED

Some College, No Degree

Vocational/Technical Degree

Associate Degree

Bachelor Degree

Masters Degree

PhD or beyond

None of these

Question Title

* 13. Do you hold any Certifications or Licensures?

Yes (please specify)

Question Title

* 14. Do you have interest in pursuing further education (Bachelors, Masters, etc) in the field of counseling, mental health or addiction studies?

Yes

Question Title

* 15. Do you have a valid Drivers License?

Yes

Question Title

* 16. Please list any additional cities or towns you lived in before you turned 18? Please include the state if not in Illinois.

Page1 / 6

17% of survey complete.