FACILITATOR APPLICATION FORM

Facilitator Application

This is a preliminary application for an Advanced Level Peer Support Facilitator.
Name
Address
Are you at least 21 years of age?
Have you previously completed a Peer Support Training?
Current Employer: Immediate Supervisor and Contact Information (supervisor will be contacted to confirm you can attend).
Name
Phone
Email
 

Past Employment (hit the + button to add more)
Past Employers
Dates
 
Diploma Earned
Diploma Earned
Diploma Earned
Diploma Earned
Max. file size: 50 MB.
Three Professional references with Contact Information (No family or friends | hit the + button to add more)
Name
Phone Number
 
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?
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?
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I understand that false or misleading information in my application or interview may result in any offer being rescinded.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
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.