Home Events Virtual Kentucky Family Leadership Academy Virtual Kentucky Family Leadership Academy Complete the registration form below! Virtual KY Family Leadership Academy - September 22nd - 24th, 2021 Name* First Last Please choose from the following*Attending as a Family Member PeerAttending as an Adult PeerAttending as a Youth PeerProviderBirth Date* Email address:* Name of second participant (if Applicable) First Last Please choose from the following for the second participantAttending as a Family Member PeerAttending as an Adult PeerAttending as a Youth PeerBirth Date of second participant (if applicable) Email address of second participant (must be a different email address). Street Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number* Please select the one that most applies to you:* I am a hired employee and my employer is sending me to this training. I'm not hired and would like to attend this training for myself. I'm going to be hired after completing this training and the Family or Youth Peer Support Certification Training. Other Employing Agency/Organization Name:* If this does not apply to you, please list N/ASupervisors Name (if Applicable)* First Last If this does not apply to you, please list N/ASupervisors Email Address Allow KPFC to use my picture or video for publicity* Yes, I give permission to use my picture or video for publicity No, I would not like KPFC to use my picture or video for publicity Academy Contract* Attend the entire training Participate to the fullest ability Let staff and peers know if I need help or assistance Show respect to facilitators and participants Complete and return all evaluations and surveys to the best of my ability Have fun at the Academy! Please read the contract , check all of the boxes before your registration is complete Total Number attending the Academy* If you are trying to register more than two people, please complete a second registration form.I will be paying my $100 registration fee by:*Credit CardMailing in the check to 600 Teton Trail - Frankfort, KY 40601Please send me an Invoice for my Employer to payI will be applying for Partial Scholarship from KPFCLeadership Academy Fee Per Person Price: Quantity*Please enter a number from 1 to 2.Total $0.00 Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name + Add to Google Calendar + iCal / Outlook export Date Sep 22 - 24 2021 Time EST 9:00 am - 3:30 pm Cost $100.00 Location Virtual Share this event
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