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* 1. First and Last Name

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* 2. Mailing Address

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* 3. Mailing Address

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* 4. Phone #

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* 5. Fax #

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* 6. E-mail Address

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* 7. I am currently employed as a

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* 8. My current school setting is

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* 9. My highest academic degree is

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* 10. My academic area of study (Major)

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* 11. Are you licensed in your professional field?

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* 12. Are you nationally certified in your professional field?

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* 13. How many years have you worked in an educational setting post highest degree?

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* 14. In the last 12 months, I have helped a student who has disclosed thoughts of suicide or attempted suicide.

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* 15. In the last 12 months, a student at my school died by suicide.

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* 16. In the last 12 months, a student at my school attempted suicide.

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* 17. In the last 12 months, a student at my current school expressed to me that they had been thinking of suicide.

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* 18. In the last 12 months, I arranged for hospitalization or help to hospitalize a student due to suicide concerns.

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* 19. Did you receive any formal training in crisis intervention?

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* 20. If marked yes above, this training adequately prepared me to help a student with thoughts of suicide. 

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* 21. Have you ever attended a continuing education, in-service training workshop, or seminar that focused on suicide prevention or crisis intervention since working in this district?

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* 22. How are you paying the fee for this accreditation program?

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* 23. I would like CE credits (no additional fee) should I achieve accreditation. I would like these from the:

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* 24. I understand this application and the subsequent training materials are non-transferable.

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* 25. The undersigned, being hereby warned that intentional or unintentional false statements and the like so made may jeopardize the validity of the application, declares that he/she/they is properly authorized to execute this application; and that all statements made of his/her/they own knowledge are true; and that all statements made on information and belief are believed to be true. By typing your name below, you are signing this application electronically.

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* 26. I understand that by making payment on the next question, I am verifying that I am eligible to complete the course and understand it is non-refundable and non-transferrable.

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* 27. We have two fee rates. Choose the answer below that applies to you. Copy and paste the link into your browser to make payment.

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* 28. How did you learn of our trainings? (social media, professional organization, membership call, colleague/friend, membership email, etc)

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* 29. Please upload your CV/Resume here

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* 30. If you are a student, upload proof of student status (current class schedule)

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