FACILITATOR APPLICATION FORM Facilitator Application This is a preliminary application for an Advanced Level Peer Support Facilitator. Name First Last PhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Are you at least 21 years of age? Yes No Have you previously completed a Peer Support Training? Yes No If yes, please provide the year you completed Peer Support Training and with what program and/or trainer.Current Employer: Immediate Supervisor and Contact Information (supervisor will be contacted to confirm you can attend).NamePhoneEmail Add RemovePast Employment (hit the + button to add more)Past EmployersDates Add RemoveEDUCATION: High School / High School Equivalent Diploma Earned Yes No EDUCATION: Vocational / Technical Diploma Earned Yes No EDUCATION: College / University Diploma Earned Yes No EDUCATION: Other Diploma Earned Yes No Please Attach a copy of your high school or GED diploma.Max. file size: 50 MB.Three Professional references with Contact Information (No family or friends | hit the + button to add more)NamePhone Number Add RemovePlease list any special skills and/or certifications:On a scale of 1-10, how would you rate your technology skills? Please explain.Do you have experience facilitating groups? Please specify.Are you able to commit to participating in four (4) sessions of the Peer Support Specialist training as part of this training process, with each session being up to two weeks long? Yes No If selected, are you able to commit to facilitating a minimum of two (2) Peer Support Specialist training sessions each year, with each training session lasting a maximum of two weeks? Yes No Why do you want to become an Advanced Level Peer Support Specialist Core Recovery Facilitator?What strengths and assets would you bring to the team of Peer Support Specialist Core Recovery Curriculum Facilitators?What Community based recovery activities do you currently participate in?What does Recovery mean to you?What factors are important in recovery?What does Peer Support mean to you?Do you think that it is important to share your story of recovery stories as part of being a Peer Support Specialist Facilitator? Explain.Conditions of payment:Participating Trainees who do not have a conflict of interest will be financially compensated for their time participating in the training in accordance with the Trainee’s written agreement with The Extra Mile Region IV. Compensation will be based on a scale with compensating increasing once a Trainee has successfully completed the training, submitting all required documentation, and becomes a Louisiana Recognized Peer Support Specialist Core Recovery Curriculum Facilitator. Trainees will only be compensated for time worked. Further details of compensation will be shared with selected Trainees by The Extra Mile Region IV. By typing my name, I certify that my answers are true and complete to the best of my knowledge. If this application leads to an employment agreement, I understand that false or misleading information in my application or interview may result in any offer being rescinded. Name First Last Date MM slash DD slash YYYY Applicants selected as a finalist will need to provide OBH and The Extra Mile Region IV a 10-15 minute video with your presentation of the 5 key concepts of Peer Support (Hope, Choice, Recovery Environment, Empowerment, or Spirituality). Video Submission: 1. You can submit your video by emailing it to [email protected] 2. Or you can submit a youtube link in the application. Please follow these instructions: If you are not sure how to upload a video to Youtube as “Unlisted” here are the instructions: – Navigate to www.youtube.com – Log-in or create an account (if you have a google account already, you can sign in easily with that account). – In the top right of the screen, click the camera icon that has a + symbol. – Click ‘Upload Video’. – Click ‘Select Files’ & choose your dance video file. – Click ‘Upload’. – Title your video with your name and ‘Peer Training Facilitator’ – Click ‘Next’ until you get to the ‘Visibility’ Screen – Select ‘Unlisted’ (Be sure you select “UNLISTED” not “private” because if it is private, we will not be able to open it.) – Click ‘Save’ -Copy the link to the video and paste into Application form in the designated field.Paste Video Link Here:
