Adult Peer Support Registration

"*" indicates required fields

Name*

First Last

Email*

Enter Email Confirm Email

Phone*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Requested Course Date*

Please click the drop down menu to select the course dates you would like to attend. Please take note that one is Weekday and one is Weekend.

Payment Source*

Please select your payment sources. Self-Pay if you will be purchasing the course yourself or third-party if an employer or grant program will be covering your tuition.

Third Party Payer's Company or Grant Program Name*

Please enter the name of the company or grant program responsible for paying your enrolment fee.

Third Party Payer's Full Name*

Third Party Payer's Email Address*

Third Party Payer's Contact Number*

Personal Motivation Statement*

Please express your personal motivation and reasons for wanting to become a Peer Support Specialist. You may want to highlight relevant experiences, personal qualities, and how you believe you can make a positive impact in the lives of others through this role.

I am 18 years of age or older.*

Yes

I am in recovery from a substance use and/or mental health disorder.*

Yes

I possess a high school diploma or a General Education Diploma (GED).*

Yes

You must provide proof of you High School Diploma or a General Education Deploma (GED) You will need this also in process of employment if you do not have a copy you can contact the Board of Education in the county you graduated or you can order a transcript of your GED.

Referral Source*

Please tell us how you heard about our class. If you are referred by a former student please be sure to name so that they can collect their referral reward.

Referral Source Name

Phone

This field is for validation purposes and should be left unchanged.