January 2025 ICISF Training Application: Normal, IL

The 100 Club of Illinois is excited to offer the ICISF Individual and Group Crisis Intervention 3 day GRIN training free of cost (value up to $400) to promote the sustainability of department and first responder critical incident resources. This course has limited seats available and a participant application is required to be considered to attend. Course seats are being held for applicants who have a strong working knowledge of the first responder culture and who will be able to implement their training immdediately through critical incident call outs and/or peer support responses.

Inidividuals who submit their application by October 18 will be notified of admittance by October 25. All other applicants will be considered on a rolling basis. If seats are unavailable for all applicants, a waitlist will be created. You will be notified regarding your course admittance via email and will be asked to respond within 2 weeks to confirm your seat for the class. Due to the high demand of this course, admission to participate may be limited to 1-2 members per agency.

Please see the course flyer and website for details of the training. If you are unable to attend all three training days, please do not confirm your availability for the class as this will take away the opportunity for others to attend.

We ask that you complete the following application in full to help us get to know you, your (or your department) needs, and your goals with fulfilling this course. Some of the questions asked in this form are for attendee grant tracking purposes and will assist with training evaluation needs.

If you have any questions regarding the course, application, 100 Club, or your department programming needs, please contact Danielle Brengel at dbrengel@100clubil.org.

Thank you!

Full Name*

First NameLast Name

Title*

Rank*

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Are you currently:*

An active duty first responderRetired first responderCivilianOther

What line(s) of work do you serve in?*

Your First Responder Wellness Role(s)*

Age:*

Race: (select all that apply)*

Gender:*

MaleFemalePrefer not to answerPrefer to self-describe as:

Agency Name*

Agency address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County agency is located in*

Agency Website*

Current Agency First Responder Wellness Programs*

Have you participated in a response from a CISM team?*

YesNoI'm not sureOther

If so, please describe your experience: what went well and what you would have changed.

Do you plan on joining an existing Illinois Critical Incident Stress Management Team (if so, which one) and/or utilizing this training for internal department purposes? *

In your current role/agency, how large is the first responder population that you could potentially serve with the skills you gain from this training?*

Are you able to serve first responders in communities outside of your immediate department or county upon request?*

YesNoOther

What current knowledge or experience about the first responder community do you have that make you a good candidate to serve this population?*

What strengths do you bring to serving first responders in this capacity?*

Describe a time that you helped a first responder during a difficult time or critical incident. Share how you talked with those first responders, how you listened to their needs, and how you provided support for yourself afterwards. *

What other first responder wellness, resilience, or critical incident response related trainings have you previously attended?*

What is your current knowledge about critical incident response for first responders?*

How or who from did you hear about this training opportunity?*

Regarding serving first responder stress or critical incident needs, rate yourself in the following categories at this time:*

	Not Very	Somewhat Very	Very	Extremely Very
Ability to assess group needs
Ability to assess individual needs
Ability to advise on identified needs
Ability to implement strategic intervention planning
Knowledge of crisis intervention strategies: Critical Incident Stress Management, Critical Incident Stress Debriefing, Crisis Management Briefing
Confidence to implement crisis intervention strategies: Critical Incident Stress Management, Critical Incident Stress Debriefing, Crisis Management Briefing
Knowledge of psychological crisis
Knowledge of unique factors first responders face as it pertains to stress and crisis

Overall, how equipped do you currently feel to serve first resonders' critical incident and stress related needs:*

1 is Not Very, 5 is Very

How much do you know about the ICISF Training modules and resources?*

1 is Not Very Much, 5 is Very Much

How much do you know about the 100 Club of Illinois resources?*

1 is Not Very Much, 5 is Very Much

What do you hope to gain from this training?*

Are you available to attend all 3 days in-full of the training dates listed?*

YesNoOther

Are you able to provide your own transportation and lodging accommodations as needed (financially and time) to attend this training?*

YesNoOther

The 100 Club of Illinois is excited to offer this training free of cost (value up to $400) to promote the sustainability of department and first responder critical incident resources. Please ensure your availability to attend. If your availability changes by the time applications are reviewed, please indicate that at the time of your application acceptance in order to allow for others to be able to attend.*

I acknowledge this agreement and am currently available to attend. If my availability changes, I will be sure to notify the 100 Club at the time of acceptance.

Please leave any other comments or questions for us regarding the training, 100 Club of Illinois, or your agency needs:

January 2025 ICISF Training Application

Individual Information

Agency Information

Critical Incident Stress Management (CISM) Teams

Training Interest

Training Pre-Survey

Training Commitment