Home Events Youth Peer Support Training Application Youth Peer Support Training Application Youth Peer Support Core Competency Training Application 2021 Name* First Last Mailing 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 Birth Date:* Date Format: MM slash DD slash YYYY Phone*Email Address (personal email address preferred)* Enter Email Confirm Email Organization NameSupervisors NameSupervisors E-mail Address1. Please discuss your behavioral health challenge and describe any state-funded services you are receiving or have received (see enclosed definition of state-funded services, page 2*2. Why do you want to become a Kentucky Youth Peer Support Specialist (KYPSS)?*3. What are your current responsibilities as a youth leader?*4. Describe any volunteer work in which you have been involved (some examples are: tutoring or mentoring other youth, school club leader/member, volunteer activities with faith community, community volunteer activities – Habitat for Humanity, Adopt a Highway, etc.)*5. What makes you a good candidate to work with other youth with behavioral health challenges?*6. Why do you think it is important for Kentucky Youth Peer Support Specialists to share their lived experience?*7. What does Family-Driven and Youth-Guided mean to you?8. Briefly describe the most valuable assistance/support you have received as a youth with lived experience.*9. This question explores your experiences or observations about team/group work: A. What are some of the advantages of being part of a team?*B. What are some of the disadvantages of being part of a team?*10. Is there anything else you would like us to know when considering you for the Youth Peer Support 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. I am a youth with lived experience who has an emotional, social, behavioral, and/or substance use disability. I have 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 have provided information in every required area of this form I understand that the Kentucky Youth 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 Youth Peer Support Specialist I understand that if I am currently employed with CMHC, that my supervisor may be contacted to discuss my training participation Payment Option*By CheckCredit CardPlease send me an invoice for my Employer to payNeed to apply for a Partial ScholarshipMake Checks payable to Kentucky Partnership for Families and Children, Inc. Mailing address: 600 Teton Trail - Frankfort, KY 40601 Youth Peer Support Training Fee Price: $300.00 Quantity: Total $0.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name + Add to Google Calendar + iCal / Outlook export Date Jul 19 - 23 2021 Time Eastern Standard Time, Testing begins after training portion each day. 8:30 am - 4:30 pm Location Virtual Share this event
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