PA CPS Training Registration Form

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Thank you for your interest in the Copeland Center Certified Peer Specialist Training. This training provides participants with the opportunity to practice the attitudes, skills, and knowledge of Peer Support. It also prepares participants to sit for the PA Certification Board Exam.

This training is a hybrid model that consists of in person class time, live zoom sessions, and independent study work.

Through a collaborative project between OMHSAS and the Pennsylvania Peer Support Coalition, we are able to offer this training at no cost.

In person sessions will be held in Indiana PA on April 2, 3, 4,15, 16, 17

This course is rooted in the concept of mutual learning. Every participant has value and knowledge the group can benefit from. To tap into the power of all of our experiences, we strive to create an environment founded in the values and ethics of Peer Support. We invite you to practice these key components of peer support through active engagement and participation in all aspects of the training. In order to participate in and complete the training and receive your certificate, you must:

· Be at least 18 years of age

· Be a self-identified individual with a mental health diagnosis and who has reached a point in their recovery pathway where they can positively support others in similar situations.

· Be willing to speak with others about your challenges with mental health and/ or trauma

· Attend all sessions & complete all work by the due dates.

I understand and assert that the statements above are true and that i will participate in all in person and Zoom sessions, as well as complete all assigned work by the due date.

I do not agree to the statement above.

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Mobile number *

email *

Do you require a reasonable accommodation to participate in this course? If so, please describe your challenges and needs. Also include a brief summary of how you will support yourself during this course. *

Please indicate if you live or work in one of the following counties. *

Clarion

Jefferson

Clearfield

Cambria

Westmoreland

Alleghany

Butler

Indiana

Armstrong

I do not live in one of the listed counties.

There will be new Peer Crisis Worker opportunities in PA. Are you interested in working in Crisis Peer Delivered Services? *

Yes

Please check all that apply:

I am a veteran

I am a member of the LGBTQ+ Community

I am between the ages of 18 and 30

I am an ethnic minority (non-white)

None

Emergency Contact - Please list a name, phone number and their relation to you.
*

How would you like your name to appear on your name tent? *

How would you like your name to appear on your Certificate? *

Facilitators may communicate with training participants by text to inform them of information important to the class. Please indicate if you would like to be included in the group text for this training. You will only be contacted regarding matters related to this training. Your phone number will not be visible to other training participants. *

I consent to receiving text messages with pertinent information about the CPS training I am attending.

Please do not send me text messages.

Are you currently working as a peer support? *

Yes

I am looking for work in peer support

I have been offered a job in peer support

I am not looking to work in the field of peer support

Photo Release Consent:

The Copeland Center may take photos during the training for use on promotional materials, website, social media, and other communications. Participants will not receive financial compensation for use of the image(s). You may retract permission for use of photos in writing. Images will be removed from digital forms of communication within 30 days. Images on printed materials will not be used in future printing.

I give the Copeland Center permission to use photos taken of me during this class in the manner described above.

I do not give the Copeland Center permission to use photos taken of me during this class.

I certified that all information provided in this application is accurate to the best of my knowledge.
*

Yes

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