Florence January 12, 2026 Refresh

........Registration Form - Florence, Alabama........ January 12, 2026

Fill out the form carefully for registration
Name*

First NameLast Name
E-mail Address*
Personal Phone Number*
Have you completed the 32-hour peer support training?*
Agency*
Are you an active or retired sworn peace officer?*
Enter either (y or n)
Are you an active, retired sworn peace officer, EMA Officer, or Dispatcher?*
Select position
How many years?*
Example: 10
Are you a Chaplain attached to a law enforcement agency?*
Enter either (y or n)
Who appointed/hired you?*
Are you a licensed mental health professional?*
Enter either (y or n)
Please provide your certification level, license #, three references (preferably law enforcement), and a brief biography along with why you want to work with law enforcement.*
This ALLEAPS course is restricted to Law Enforcement Officers, EMA Officers, 911 Dispatchers, Chaplains, and Licensed Mental Health professionals.

You do not meet the minimum requirements for this course.
Should be Empty:

........Registration Form - Florence, Alabama........ January 12, 2026