Application for the Great Lakes PTTC Change Leader Academy for Prevention Professionals 2024  
Complete the form below to apply for the Change Leader Academy for Prevention Professionals. The Academy will take place via Zoom on March 6, 13, 20, and 27 from 9:00 -11:00 a.m. Central Time (10:00-Noon Eastern Time).

IMPORTANT: This Academy is not a webinar series. Active participation with camera on and face visible throughout each session is essential. Homework that will take approximately one hour to complete will be assigned between each session. In order to receive a certificate of participation for this course, all prep work must be completed and participation in all sessions with camera on and full face visible is required.

AUDIENCE: Substance misuse prevention practitioners located in HHS Region 5: Minnesota, Michigan, Ohio, Illinois, Indiana, and Wisconsin. If you live outside Region 5, you are welcome to complete the application and be placed on the wait list. Individuals from outside Region 5 will be accepted as space is available.
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Email *
Your first name *
Your last name *
Email address *
Phone number *
City *
State *
Zip code *
Please describe your current role in the substance misuse prevention field. *
Are you able to commit to participating in all Zoom sessions (March 6, 13, 20, 27 from 9:00-11:00 AM CT)? If no, please explain. * *
Are you able to commit to completing the reading and prep work (approximately 1 hour of work) between each sessions? If no, please explain. *
Are you able to commit to active participation, including being on camera with your full face visible and audio during each session via Zoom? If no, please explain. (Please note: We ask that participants do not "Drive and Zoom" for safety reasons.) *
Does your supervisor understand and support the time commitment you are making to this course including the 4, 2 hour sessions and 1 hour of homework between each session? *
I understand that in order to receive the certification of participation, I must attend all four Zoom sessions with my camera on and face visible and I must submit my completed homework between each session by the deadline. *
Comments and/or questions:
A copy of your responses will be emailed to the address you provided.
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