First Name:
*
Middle Name:
Last Name:
*
Enrollment for:
FIC-Milwaukee, WI - February 13,
2009
How did you learn
about these training programs?
*
Organization/Agency Information:
Name:
*
Your
Title/Position: *
Address:
*
City:
*
State\Province:*
ZIP\Postal Code:
*
Telephone:
*
Fax:
Email:
*
Federal Tax ID #:
Are You/Your Agency
An FEI EAP Affiliate?
Yes
No
Affiliate #:
Personal
Information:
Home Address:
City:
State\Province:
ZIP\Postal Code:
Telephone:
Pager:
Cell:
Email:
Social Security #:
Special
Accommodations Needed During Training:
Education/Experience:
Highest Degree
Earned:
Major area(s) of
study:
Years Of
Professional Experience:
License/Certification Type:
License/Certification State/Province:
License/Certification #:
Expiration Date:
Special
Skills/Training:
Foreign Languages
Spoken:
Training
Questions:
All answers
will be kept strictly confidential. The nature
of this work will require skills in crisis
intervention and post trauma support. This work is
short term in nature involving high intensity
situations and can be very stressful. Please keep
this in mind as you respond to the following (please
be brief):
1. I relax by:
*
2. What I value
most is: *
3. People who have
recently been traumatized need:
*
4. Briefly describe
any specialized education/ training and/or
experience you have had in crisis intervention
and/or post trauma intervention services:*
5. Keeping in mind
that this work demands a great deal of flexibility,
the three major reasons I am interested in this work
include: *
6. Optional:
Is there anything else you would like us to know?
Travel Questions:
Name/Location of
closest airport to your:
Home:
Work:
Other Airports
within 100 miles:
Are you willing to
travel internationally?
Yes
No
Do you have a valid
passport?
Passport #:
Expiration Date:
Yes
No
(If yes, complete the next two
fields)
Do you have any
travel restrictions?
Explanation of
travel restrictions:
Yes
No
Are there regions
of the world where you would rather not travel to?
Please specify
regions:
No
Yes
(If yes, complete the next field)
Please note any
special accommodations you may need when traveling:
Please complete
the following questions only if you are applying for
the Crisis Support Coordinator Role:
Please note that in
addition to the above information, we will also also
need a copy of your resume, and if applicable a copy
of your state license/certificate, previous training
certificate(s) and proof of professional liability
insurance with limits of $1 million per occurrence
and $3 million per aggregate. Although these
are not required at the time of training
registration, it is helpful to both you and FEI to
send these materials at your earliest convenience
to:
FEI Behavioral
Health
Title of Course or
Program:
Date of Completion:
Length and type of
experience:
FEI
Behavioral Health reserves the right to modify or
cancel training programs with 5-day notice to
registered participants by telephone, fax or email.
