Clone of 12 Step Certification Scholarship Application

Mending Broken Hearts Certification Scholarship Application
The Cheyenne and Arapaho Tribal Office of Recovery is hosting a 3 day Wellbriety certification course for the Mending Broken Hearts curriculum from February 18-20 located at 4400 SW 21st St in Oklahoma City. Attendance is required each day from 8:00am-5:00pm.

This is an opportunity to earn this $500 certification for free. Space is limited and applicants will be confirmed by February 1st.
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail
example@example.com
Tribal Affiliation
Sober Date:*
Will this be your first White Bison Certification?

YesNo
If no, have you already earned your Mending Broken Hearts certification?

YesNo
What community will you implement this curriculum in?
How will you implement this curriculum in your community?
Do you have reliable transportation to attend all three days of training?

YesNoMaybe
Should be Empty:

Mending Broken Hearts Certification Scholarship Application