Please enable JavaScript in your browser to complete this form.Name *FirstLastProfessional Title / Occupation *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryPhone *Email *EmailConfirm EmailEmployer *(i.e., the name of the organization you work for)Desired Training Date *September 27-28, 2022October 19-20, 2022Alternate Training Date (should your desired date above no longer be available) *September 27-28, 2022October 19-20, 2022Keep me informed on the next available dateStarr Certifications Achieved *CTRPACTRPCTRCApplicants must be an active CTRP, CTRC, and/or ACTRP and have completed all five required courses for applications to be reviewed and approvedEducationCollege/Educational Institution(s) *Years of Attendance *Degree(s) and or Certificate(s) Achieved *Work ExperienceCurrent Title and Duration of Employment (e.g., 2014-Present) *Previous Title and Duration of Employment (e.g., 2012-2014) *Previous Title and Duration of Employment (e.g., 2011-2012) *Related Expertise *Describe any applicable training, supervision, professional speaking and/or published work you have completedProfessional Development *Describe any recent professional development, growth activities, and/or literature you have completed recentlyReferencesPlease provide three references, one of which who is in a leadership postion at your current place of employment (and can attest to your training/facilitation abilities)Leadership Reference Name *FirstLastPlease Note: This individual should hold a leadership position at your current place of employmentLeadership Reference Email *EmailConfirm EmailProfessional Reference #1 Name *FirstLastProfessional Reference #1 Email *EmailConfirm EmailProfessional Reference #2 Name *FirstLastProfessional Reference #2 Email *EmailConfirm EmailPersonal Attributes and ExperiencesStrengths *Describe what strengths you would bring to the role of a trainerVolunteer Experience(s) *Describe any community involvement, service memberships, etc. you are part ofPersonal Philosophy *Describe your approach to working with youth in 100 words or lessTrainer DetailsTraining Audience *Describe the audience and location(s) you would like to train Trainer Goals (Optional)Describe what goals you would like to achieve as a Certified Trauma and Resilience Trainer Submit