EmailMe Form - Program Leader Application

Your Name *

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Email *

All NAMI Program Leaders must be current members.
Are you a member of NAMI? *

Yes

No

I plan to be

If yes, which affiliate ?

Are you a person with lived experience with a mental health condition or a family member or caregiver of someone one with symptoms of a mental health condition? *

Yes

No

If a family member, what is your relationship to that person?

Are you or a family member have been or currently a member of the armed forces?

Yes

No

Which NAMI program are you interested in becoming a Program Leader? Check all that apply. *

Are you willing to participate in and complete one of the program classes you're interested in (NOTE: Recommended, but not required)

Yes

No

Maybe

I prefer to teach: *

In-person

Via Zoom

Both

I am available to teach: *

Afternoons

Evenings

Weekends

All of the above

In 5-10 sentences please describe your personal experience with mental health conditions (your own, your loved one's or both). *

Why do you want to become a NAMI Program Leader? *

Emergency Contact Name *

First Last

To protect our online meeting trainees, we ask all participants to provide us with an emergency contact person that we could contact ONLY in the event of an emergency. This information is kept completely confidential - it will never be sold or shared.

Emergency contact relationship to registrant

Emergency Contact Phone Number *

How did you find out about NAMI Emerald Coast?

I understand that all NAMI programs are copyrighted. I will adhere to the Program Operating Policies and Conduct of Conduct (to be reviewed during your training, if selected), and I will present or facilitate according to these policies at all times.

I understand that my attendance at the NAMI Program Training does not guarantee that I will be certified as a Program Leader. If I receive the certification, I understand/agree to serve as a leader in three classes during a two-year commitment, or close to these time limits. The time, energy and expense of training each facilitator make this a necessity. It is understood, of course, that unexpected situations may occur that will necessitate compassion and flexibility in this policy.

I agree to only use approved NAMI Program materials that are provided in my Leader Manual. I also agree to send all reports to the NAMI Emerald Coast Director of Programs.

By entering your name and the date below, you are acknowledging the above mentioned statement. *

First Last

Date *

MM / DD / YYYY