CPS Training Registration Form: July 2024, Pottsville PA

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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. In Person trainings will be held in Pottsville, PA.

Training dates and times are as follows:

July 17-19: In-Person 9:00am - 5:00pm

July 22-26: Online 10:00am - 2:00pm ET

July 29-31: In-Person 9:00am - 5:00pm

Through the ARC P.O.W.E.R. Grant awarded to the Pennsylvania Peer Support Coalition (PaPSC), this training is being offered free of charge. People who live in the ARC region of PA will be given priority seating in this training. Please select the option that applies to you: *

I live in one of the following counties: Allegheny, Armstrong, Beaver, Bedford, Blair, Bradford, Butler, Cambria, Cameron, Carbon, Centre, Clarion, Clearfield, Clinton, Columbia, Crawford, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lawrence, Luzerne, Lycoming, McKean, Mercer, Mifflin, Monroe, Montour, Northumberland, Perry, Pike, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, and Wyoming

I live in a county other than those listed above.

In order to become Certified as a Peer Specialist in PA, there are requirements that must be met as outlined below. In order to participate in this training, 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.

This is a hybrid training. You will need access to a computer, webcam, microphone, and internet access to complete this training. *

Yes, I have consistent access to the required technology

No, I do not have consistent access to the required technology

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Mobile number *

email *

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

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. *

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

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

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

Required

To receive a certificate for the training you must:

· Complete all assignments by the due date

· * Attend all in person and Zoom sessions in their entirety

· Actively participate during in person trainings and Zoom sessions

· Complete all independent study work

· Complete all Practice Elements

*The Copeland Center reserves the right to excuse absences and assign makeup work and make up sessions at our discretion. Documentation is required for all absences.

Standards of Personal Conduct

The Copeland Center endeavors to maintain a positive and productive training environment rooted in wellness. Facilitators and participants play a role in fostering this environment. Accordingly, we all must abide by certain rules of conduct, based on honesty, common sense and fair play.

Because everyone may not have the same idea about proper workplace conduct, it is helpful to adopt and enforce rules all can follow. While facilitators will make good faith attempt to work with people in violation of the rules below, unacceptable conduct may subject the offender to dismissal from the training/ workshop. The following are examples of some, but not all, conduct which are considered unacceptable:

• Stealing, removing, or defacing property that belongs to the training site, Copeland Center, contracted facilitator, and/or training/workshop attendees

• Violation of training site safety rules and policies.

• Use of illicit drugs or alcohol during training/workshops (including lunches and breaks) or attending training under the influence of such substances.

• Violation of the Punctuality and Attendance Policy, including but not limited to irregular attendance, habitual lateness, or unexcused absences.

• Violation of The Copeland Center's Harassment Policy.

• Consistent disruptive behavior.

*Participants will receive a digital copy of the training policies and procedures.

I understand and agree

I do not agree to the terms outlined above

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.

Were you referred by anyone? If yes, please provide the name of the person who referred you. If no, please type no. *

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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