Recovery Coach Academy Application Form

Recovery Coach Trainings Application

CARC Trainings - CCAR Curriculum

Facilitators Rich Hollett and Gianna Sandelli

Email*

example@example.com

Todays Date:*

Date

Full Name*

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Format: (000) 000-0000.

DOB*

Referal Information (Name, Agency, etc.)

Please list your current employment information including: Company and/or Program, Position Title, Address/Location, Supervisor Role and Contact Information:

GEDHigh School DiplomaNo, I have not obtained either a GED or HS DiplomaOther

Referal Information Name Agency etc*

Recovery Coach Academy:Ethical Considerations:

YesNo

If you answered yes; please list your Recovery Coach Supervisor information below (Supervisor name, Title, Company, contact information)

YesNoOther

If you answered no to the previous question, please state why you are interested in taking the RCA:

YesNoOther

If no; please identify how a SUD has affected you in your lifetime:

Please tell us a little about yourself, including strengths, experiences, etc. that has led you to applying to participate in the RCA (5-8 sentence maximum):

If you have been referred by someone to apply for this training, please list name and affiliation below: