Peer Recovery Coach Scholarship Peer Recovery Coach Scholarship (Please read and answer each question carefully) Name(Required) First Last Email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)What best describes you?(Required)Mark only one oval. Woman Man Transgender Nonbinary No Answer Other What best describes you?(Required)Mark only one oval. Black/African American Native American Hispanic/Latine Asian/Pacific Islander White No Answer Other Are you a Recovery Court (ACDC, HEALS), DUI Court, DV Court, or Veterans Trauma Court graduate or participant?(Required)Check all that apply. Yes No Are you an FTDC Graduate or Participant?(Required)Check all that apply. Yes No If you answered yes to either of the previous questions, what phase are you in? Are or were you involved in Corrections?(Required)Mark only one oval. Yes No Have you ever been hospitalized due to substance use disorder?(Required)Mark only one oval. Yes No Have you ever served in the military?(Required)Mark only one oval. Yes No Are you receiving SNAP benefits? *(Required)Check all that apply Yes No Are you willing to disclose to other people that you are in recovery from substance use disorder and/or mental health diagnosis or share what’s it’s like to be a friend or family member of someone with substance use disorder and/or mental health diagnosis?(Required) Yes No Can you describe what has helped you move from where you were to where you are now? Briefly explain:(Required) Please state how long you’ve been in recovery.(Required)Can you describe how you deal with difficult situations? With setbacks?(Required)How did you hear about the training academy? (If you are a volunteer, please state volunteer program.)(Required) What class from the Peer Recovery Coach Training Academy catalog are you interested in taking?(Required) Are you currently working in the recovery field? If so, what agency?(Required) If you are requesting financial assistance, please summarize your needs.Participation and being present includes camera on when on zoom, only when in a still and quiet environment, and fully participating whether on zoom or in person for 90% or more of the allotted class time. Checking yes constitutes an understanding and agreement that these requirements will be met, and understanding that a certificate may be denied, and class retaken(Required) Yes No I acknowledge SRC's nonprofit status and limited resources. I understand scholarships are not guaranteed, and I may be asked to find alternate funding for my training.(Required) Yes No
