Home Events Family Peer Support Specialist Core Competency Training Family Peer Support Specialist Core Competency Training Family Peer Support Core Competency Training Application Name* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Birth Date* Date Format: MM slash DD slash YYYY Phone*Email* Enter Email Confirm Email Organization NameSupervisors NameSupervisors E-mail addressPlease list your child’s diagnosis/diagnoses and describe any state-funded services they are receiving or have received (see packet for definition of state-funded services, page 2)*Why do you want to become a Kentucky Peer Support Specialist (KFPSS)?*What are your current responsibilities as a full-time caregiver and/or employee?*Describe any volunteer work you have been involved in (some examples are: PTA president, Scout Leader, Habitat for Humanity, Neighborhood Association, Sunday School/Youth Leader).*What makes you a good candidate to work with other parents and caregivers of children with mental health/substance use challenges?*Why do you think it is important for Kentucky Family Peer Support Specialist to share their experiences?*What does family-driven and youth-guided mean to you?*Briefly describe the most valuable assistances/support you have received as a parent/caregiver.*This question explores your experiences or observations about team/group work.What are some of the advantages of being part of a team?*b. What are some of the disadvantages to being part of a team?*Is there anything else you would like us to know in considering you for the Core Competency Training?*Provide the following information by indicating “yes” with a CHECK mark.* I meet the criteria outlined in the packet under eligibility section of this application. The child mentioned above is or has been a consumer of at least one state-funded service for children with an emotional, social, behavioral, and/or substance use disability I have successfully completed the Leadership Academy offered by KPFC and have attached/included a copy of my certificate of completion I completed a minimum education of High School and have attached a copy of my diploma or transcript I completed my GED coursework and have attached a copy of my GED certificate I completed and have attached the Short Essay Form I have provided information in every required area of this form I understand that the Kentucky Family Peer Support Specialist Training is not a job placement program and completion of the training does NOT guarantee that I will be hired as a Kentucky Family Peer Support Specialist I understand that if I am currently employed with CMHC, that my supervisor may be contacted to discuss my training participation I am requesting a waiver for the thirty-five (35) hours training in accordance with this administrative regulation. Enclosed is the required documentation for the waiver Upload Files, Diploma etc. Drop files here or Family Peer Support Certification Training Price: $300.00 Payment Option* By Check Please send me an invoice for my Employer to pay Need to apply for a Partial Scholarship Make Checks payable to Kentucky Partnership for Families and Children, Inc. Mailing address: 600 Teton Trail - Frankfort, KY 40601 + Add to Google Calendar + iCal / Outlook export Date Jan 25 - 29 2021 Time 8:30 am - 4:30 pm Cost $300.00 Share this event
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