Fresno County Pre-Registration Form for Onsite/In-Person Medi-Cal Peer Support Specialist Certification Training May 19-June 2, 2025

To pre-register, you must complete each response

Please note that the pre-registration will not be complete unless all questions are fully answered. Thank you! The training is 10 days (two weeks), M-F, 8:30 am- 5:00 pm, with a one hour lunch break. The training dates are May 19 through June 2, 2025. Participants may not miss more than 8 hours total. Please note that the pre-registration is not a guarantee of enrollment. After individuals pre-register and we get about 2-3 weeks out from the start date of the training, you will start receiving requests for your response. Only those who are responsive in a timely manner will be enrolled. Those who are not responsive or are late in their response may be wait listed for a future class.

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* 1. What is your full name?

First Name

Last Name

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* 2. Choose your training dates. Please note that the class size is limited in order to keep the learning experiential and supportive. There is a chance that you may be waitlisted for a given date selection. You will be notified as soon as practicable if you will be waitlisted. After you pre-register, we contact you through email to schedule your required 1.5 hour orientation and full registration. Individuals who respond to our emails and show up for their scheduled orientation are prioritized.

May 19- June 2, 2025, Monday through Friday, 8:30 am- 5:00 pm

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* 3. What is the best phone number to contact you?

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* 4. What is your email address?

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* 5. In a few words, please describe your interest in this training program.

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* 6. Participating in this training program requires you to have a lived recovery experience defined as personal experience of being a consumer of mental health or substance use disorder services, or as a parent, family member or direct care supporter of someone who does. Do you have a lived recovery experience, as defined here?

Yes

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* 7. What is your employment or volunteer status?

Yes. I am employed part time (20 hours or less per week).

Yes. I am employed full time (36-40 hours per week).

Yes. I am an unpaid volunteer

No. I am unemployed and I do not currently volunteer.

Fresno County Pre-Registration Form for Onsite/In-Person Medi-Cal Peer Support Specialist Certification Training May 19-June 2, 2025

To pre-register, you must complete each response

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* 1. What is your full name?

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* 3. What is the best phone number to contact you?

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* 4. What is your email address?

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* 5. In a few words, please describe your interest in this training program.

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* 7. What is your employment or volunteer status?

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* 8. What is the title of your employment/volunteer position? In unemployed or not volunteering, please enter NA (for not applicable).

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* 9. What is the name of your employer & program or volunteer placement site? In unemployed or not volunteering, please enter NA (for not applicable).