In Our Own Voice Presenter Application

Question Title

* 1. Please provide your contact information below:

Full Name

NAMI Affiliate

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Primary Phone Number

Question Title

* 2. What is your age?

Question Title

* 3. Do you have a NAMI membership? If you are not a current NAMI member, you must become one prior to the training. Memberships are available starting at $5. Click here to become a member.

Yes

Unsure

Question Title

* 4. If yes, which email is connected to your NAMI membership/login?

Question Title

* 5. Have you seen an In Our Own Voice (IOOV) Presentation?

Yes

Unsure

Question Title

* 6. Have you attended other NAMI courses or classes? If yes, please describe:

Question Title

* 7. Are you a currently certified to teach/lead any other NAMI Signature Programs? If yes, please list:

Question Title

* 8. Do you have access to a computer and Internet for this training?

Yes

Unsure

Question Title

* 9. Please Answer The Following Questions In 1-2 Sentences: Describe why you would like to become an In Our Own Voice presenter.

Question Title

* 10. Describe your experience as a person with lived experience, and what recovery means to you.

Question Title

* 11. Describe your work/ volunteer experience and/ or qualifications to become a presenter.

Question Title

* 12. Presenter Requirements (please check off that you agree to all of the following requirements):

I am a person with lived mental health experience.

I am or will become a NAMI member.

I understand that my participation in this virtual training does not guarantee that I will be certified as a presenter.

I will commit to meeting with the NAMI Connecticut staff and complete the required practice/training.

If certified, I will make every effort to deliver 3 presentations per year.

I will communicate promptly with the NAMI Connecticut state office, as requested or required, and will submit
all forms and data to the state and national offices, as required by an In Our Own Voice Presenter.

I agree to be a presenter for In Our Own Voice for a minimum of two years to help meet the needs of my
Affiliate.

I understand that IOOV Presentations are not intended to recommend or endorse specific medications or
therapies, but instead to educate and empower all audience members.

Question Title

* 13. Is there anything else you'd like to share?

Question Title

* 14. Which of the following languages do you speak most fluently in? (Please select all that apply.)

Arabic

Cantonese

Mandarin

English

French

German

Korean

Russian

Spanish

Tagalog

Vietnamese

Other (please specify)

Question Title

* 15. How did you hear about this program/ training?

Question Title

* 16. What is your race or ethnicity?

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Multiracial or Multiethnic

Native American or Alaska Native

Native Hawaiian or other Pacific Islander

White

Another race or ethnicity, please describe below

Self-describe below:

Question Title

* 17. What is your gender?

Female

Male

Transgender

Non-binary

Prefer not to answer

Other (please specify)

Question Title

* 18. Signature (by typing your name in the above box you confirm that all information in this application is true).

Question Title

* 19. Today's Date

Date / Time

Date