Registration Form What is your full name? (Perferred Name) * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Ethnicity * What is your Ethnicity/Race? Phone * (###) ### #### Email * What impact will completing this training have for you within your community? * What is your age? Under 18 18-24 25-34 35-44 45-54 55-64 65+ What are your pronouns? How did you hear about Purple Orchid Peer Support Specialist training? Will you continue to partner and support this project after completion of training? Yes No If accepted into the Purple Orchid Peer Specialist training program, are there obstacles that will prevent you from completion? Yes No Are you aware that this training requires participation and feedback? * Yes No How well do you work with others? Strongly Disagree Disagree Neutral Agree Strongly Agree Thank you!
