Intentional Peer Support Registration, Summer 2018

Registration Request Form

This form is intended to request registration for the Intentional Peer Support 5-day Core Training scheduled for Monday, July 9 through Friday, July 13 at Holyoke Community College in Holyoke, Massachusetts.

Please note that filling out this form constitutes a REQUEST to register. Confirmation of registration will be sent as soon as possible, and no later than June 1. You are not formally registered until you have received confirmation.

Question Title

* 1. Please complete all fields below.

Name *

Company

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country

Email Address *

Phone Number *

Question Title

* 2. Tell us a bit about who you are in relation to this training.

I am working in a peer role in a peer-to-peer organization (RLC, etc.)

I am working in a peer role in a clinical organization (CBFS, Emergency Services, etc.)

I am not working in a peer role right now, but I hope to work in a peer role in the future.

Other (please specify)

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* 3. Are you able to attend all five days of the training? (Please note that attendance at the majority of the training is required to successfully complete the course.)

Yes.

No.

Other (please specify)

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* 4. If you are unable to attend all five days of the training from start to finish, please tell us more about what you'd need to miss.

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* 5. Are you or your employer able to pay the $140 registration fee?

Yes

No. I am requesting a reduced or free registration scholarship.

Intentional Peer Support Registration, Summer 2018

Registration Request Form

Question Title

* 1. Please complete all fields below.

Question Title

* 2. Tell us a bit about who you are in relation to this training.

Question Title

* 3. Are you able to attend all five days of the training? (Please note that attendance at the majority of the training is required to successfully complete the course.)

Question Title

* 4. If you are unable to attend all five days of the training from start to finish, please tell us more about what you'd need to miss.

Question Title

* 5. Are you or your employer able to pay the $140 registration fee?

Question Title

* 6. If requesting financial assistance, are you requesting a free registration or a reduction? If a reduction, how much are you able to pay?

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* 7. If requesting financial assistance, can you tell us a bit about how you intend to use this training, or how you think it will benefit you?