Family Peer Support Worker Certification Registration

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Training Title

Family Peer Support Worker Initial Training

Date/Time Selection(Required)

Choose one from the date(s) below.

May 9-11, 2023 and May 16-18, 2023 9:00AM-4:00PM

Name(Required)

As it appears on your driver's license.

First Last

Primary Email(Required)

Enter Email Confirm Email

Alternative Email(Required)

Enter Email Confirm Email

Primary Phone(Required)

Alternative Phone(Required)

What is your role in attending this training:(Required)

An approved FPSW Candidate (must have committee approval)
I will be observing this training.
Other (please specify)

Training Role-Other

Job Title(Required)

Within your agency. If unemployed, enter "NA."

Agency/Organization:(Required)

Agency/Organization-Other

Agency Name

Organization Location/Service Area(Required)

Participant Category(Required)

Please pick the role that best defines your role in attending this training.

Participant Category-Other

Mailing Address(Required)

For receiving your training manual. Make sure to use an address that can accept the manual when it arrives. Otherwise, you won't receive your manual in time.

Street Address Address Line 2 City State ZIP Code

Statement of Understanding(Required)

I understand that participation in this training includes ensuring I have a reliable computer with stable internet connection and working audio and visual capabilities
I agree to keep my camera on whenever possible and to stay actively engaged throughout the training

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Family Peer Support Worker Certification Registration

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