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Upstream Academy Application

Please be ready to fully complete this application before you begin. Completion of the application, once you have gathered all your reference letters, should take approximately 30 minutes. Reference the FAQ page for required documents and information. Completion of this application does not guarantee admission into the Academy. Incomplete applications will not be accepted.
1.Please provide your personal information below:(Required.)
2.Our goal is to secure at least one Academy member from each Kentucky county. Please list the name of the county you will be representing.(Required.)
3.If you are accepted as an Academy member, will you be conducting these tasks as part of your employment with an agency or organization? For example, will you be attending all informational sessions and conducting presentations and trainings while working for an employer?(Required.)
4.If you are currently employed, please list the following information for your place of employment. If you are not currently employed, please skip this question and move to the next question.
5.Is your employer a member of the PCAK Partners in Prevention Network?
6.Please upload a letter of recommendation from your immediate supervisor. The letter must be on letterhead and must include a signature. If you are participating in the Upstream Academy while on work time, this letter must include a statement from your supervisor indicating they agree with the time commitment required to participate. You can find these time commitments on the FAQ page. If you are self-employed, retired or unemployed, please provide a letter of reference from a past employer, community partner, or reference.
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7.Please provide the name of your immediate supervisor and contact information. If you are not currently employed, please skip this question and move to the next question.
8.Will honorarium/stipend payments for participation be made to you as an individual or to your employer?(Required.)
9.Please indicate your preferred methods of communication.(Required.)
10.Do you have experience providing trainings or presentations? Please summarize these experiences in the space provided. Be sure to include the types of trainings (content or topics), presentations, and audience demographics (target audience, size of audience). Limit your response to 150 words or less.(Required.)
11.Please provide two references who can attest to your training or presentation expertise and/or overall experiences successfully working with communities, groups, or individuals.(Required.)
12.Upload a resume outlining your work history and experiences that showcase your abilities to become an Upstream Academy Member.
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13.You may upload any evaluation summaries or letters of support highlighting your trainings or presentation skills. Not required but may be used to help support your application. Only submit a maximum of three uploads.
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14.You may upload any evaluation summaries or letters of support highlighting your trainings or presentation skills. Not required but may be used to help support your application. Only submit a maximum of three uploads.
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15.You may upload any evaluation summaries or letters of support highlighting your trainings or presentation skills. Not required but may be used to help support your application. Only submit a maximum of three uploads.
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16.Please tell us why you want to be a member of the Upstream Academy. Please limit your response to 150 words or less.(Required.)
17.When you are providing a training/presentation, what strategies do you use to engage participants and ensure they are actively involved in the learning experience. Please limit your response to 150 words or less.(Required.)
18.Upstream Academy Members will be required to participate in and adhere to upstream prevention practices. Carefully read each area of practice below and check the box beside each practice area to agree to the terms of the Academy.
19.If selected as an Upstream Academy Member, I agree to attend one of the in-person Academy Sessions and Graduation Ceremonies.(Required.)