Family Support Group Facilitator Training Application

June 23 & 24, 2018

Providence Willamette Falls Medical Center

1500 Division St.
Oregon City, OR, 97045

Applications Due by: Friday June 8, 2018

• Please include a letter of reference from a NAMI affiliate leader.

• Applicant must be a current NAMI member or join NAMI by the application due date.

• A phone interview will be conducted.

PLEASE PRINT LEGIBLY or Compete and Save in Microsoft Word.

Name:
Home Address:
City/State/Zip:
Home Phone:
Cell Phone:
Email:
NAMI Member? Yes: No: My affiliate is (check one):
Central Oregon / Clackamas County / Clatsop County / Columbia County
Coos County / Douglas County / Klamath County / Lane County
Marion/Polk Counties / Mid-Valley/Benton County / Multnomah County / Southern Oregon
Washington County / Yamhill County / Other

Do you have your own transportation? Yes: No: Use public transportation? Yes: No:

Support Group Facilitator Requirements:

·  Willingness to undergo training and to adhere to fidelity to the Support Group Facilitator model.

·  Commitment to begin to co-facilitate a support group within 6 months of training.

·  Commitment to facilitate a support group for at least 12 months over the next two years.

·  Commitment to communicate with NAMI Oregon state office as requested.

·  Commitment to provide group participant data to NAMI Oregon as required.

·  Willingness to identify potential new facilitators from your support group.

·  Positive regard for, or personal experience with, mutual support.

·  Willingness to authorize a criminal background check.

Please check box to indicate that you have read and agree to the above requirements.

Availability to facilitate a support group (please check all that apply):

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
Morning
Afternoon
Evening

Participant Survey

Have you ever been convicted of a felony? / Yes No

If yes, please explain:

Have you taken other NAMI classes or trainings? Please list below.

Please briefly describe why you want to become a Family Support Group Facilitator:

Lodging/Dietary Needs

Do you require a handicapped-accessible training facility? / Yes No
Do you require lodging for the training? / Yes No
Do you require a handicapped-accessible room? / Yes No
Are you willing to share a room* (if hotel accommodations are offered): / Yes No
Gender (used only for lodging arrangements): Male Female Neither
If hotel offered, you would like to share with:

*For trainees travelling 50 miles or farther, NAMI Oregon will arrange and pay for double-occupancy lodging near the training site. Trainees requiring private rooms will need to arrange and pay for their own lodging. If you accept lodging offered by NAMI Oregon but must withdraw from the training before it begins, you MUST contact NAMI Oregon ASAP so the lodging reservation can be canceled without paying a penalty.

Please list any special needs for accommodations or meals, including food or other allergies**:

**Some meals, snacks, and beverages are provided throughout the training. Consult the training schedule to see which meals are provided. We can usually provide vegetarian meals. Trainees with other dietary restrictions should plan to supplement the food provided by bringing items from home.

Return Applications and Letters of Reference to:

Peter Link, Education Programs Manager

NAMI Oregon

4701 SE 24th Ave., Suite E

Portland, OR 97202

Fax: 503-230-2751

Email:

Page 3 of 3 rev. Oct 2017

4701 SE 24th Ave., Suite E, Portland, OR 97202

503-230-8009