Training Course Information Request (Website Waitlist)

Training Course WAITLIST Request
Completing this form DOES NOT register you for a training.
To register for a training that is currently scheduled (and appears above), select/ tap/ click that specific event to go to the event information page. Select the "Register Now" button and complete the application.
Date of Request

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameMiddle NameLast NameSuffix
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Confirm Email
example@example.com
SURVEY QUESTION: Are you currently working for a Southeast Florida Behavioral Health Network or Palm Beach County Provider/ Agency? (Check all that apply.)

Other
SURVEY QUESTION: What is the name of your organization?
Course Fee and Payment Responsibility

While we do offer some free training classes, many have a fee to cover materials and facilitator costs that ranges from $50 to $250 depending on the training. (Group rates are available: email training@rebelrco.org)
SURVEY QUESTION: For any course that requires a fee, who is responsible for paying for you to attend?
To Receive An Email

Select the course you wish to receive an email notification for once registration for it is opened. One request per submission - - You may make additional requests once you submit the form.
Select the course you are interested in attending:
Qualification Questions:

Please answer the questions below. You must have completed WRAP Seminar 1 PRIOR to joining this waitlist.
Select "Yes" to join the waitlist for From Peer to Practice (40 Hours) CRPS training.
Are you seeking your credential to become a Certified Recovery Peer Specialist (CRPS)?
When do you plan to take the CRPS exam?
Qualification Questions:

Please answer the questions below. You must have completed WRAP Seminar 1 PRIOR to joining this waitlist.
Select "Yes" to join the waitlist for Wellness Recovery Action Plan (WRAP) Seminar 2 Training (40 Hours).
Have you completed WRAP Seminar 1?
WRAP 1 Completion Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
THE NAMES OF YOUR FACILITATORS CAN BE FOUND ON YOUR CERTIFICATE OF COMPLETION.

THERE SHOULD BE AT LEAST 2 NAMES:
Facilitator 1 Name

First NameLast Name
Facilitator 2 Name

First NameLast Name
Which agency or provider facilitated your WRAP 1 training?

Other
WE NEED A COPY OF YOUR WRAP 1 CERTIFICATE OF COMPLETION. You may submit a picture of it using this form (see below)

OR skip and submit this form. You will receive a confirmation email. Please REPLY BACK to this confirmation email and attach the scanned copy or picture of your certificate.
Please include a photo of your WRAP 1 Certificate of Completion.
...or add photo:
REBEL USE ONLY
Date of 1st Invite

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Outcome 1
Date of 2nd Invite

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Outcome 2
Please verify that you are human
Should be Empty:

Training Course WAITLIST Request

Completing this form DOES NOT register you for a training.

Course Fee and Payment Responsibility

To Receive An Email

Qualification Questions:

Qualification Questions: