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 How did you hear about the training academy?(Required) Please explain your knowledge or expectations of peer recovery coaching.(Required)What class from the Peer Recovery Coach Training Academy catalog are you interested in taking?(Required) Are you able to fully commit to the training? (ample bandwidth to be on zoom if training virtually and personally) Class requires attention and participation.(Required)Do you or a close friend/family member have a history of substance use disorder? If yes, please tell us a little about the journey. Please include how long you have been on this recovery journey.(Required)Section BreakPLEASE ANSWER THE NEXT 10 QUESTIONS AS HONESTLY AS POSSIBLE. BRIEF ASSESSMENT OF RECOVERY CAPITAL Instructions: On a scale of 1 (Strongly disagree) to 6 (Strongly agree), please indicate your level of agreement with the following statements. 1. There are more important things to me in life than using substances. *(Required)Mark only one oval 1= strongly disagree - 6 strongly agree 1 2 3 4 5 6 2. In general I am happy with my life.(Required)Mark only one oval 1= strongly disagree - 6 strongly agree 1 2 3 4 5 6 3. I have enough energy to complete the tasks I set myself.(Required)Mark only one oval 1= strongly disagree - 6 strongly agree 1 2 3 4 5 6 4. I am proud of the community I live in and feel part of it.(Required)Mark only one oval 1= strongly disagree - 6 strongly agree 1 2 3 4 5 6 5. I get lots of support from friends.(Required)Mark only one oval 1= strongly disagree - 6 strongly agree 1 2 3 4 5 6 6. I regard my life as challenging and fulfilling without the need for using drugs or alcohol.(Required)Mark only one oval 1= strongly disagree - 6 strongly agree 1 2 3 4 5 6 7. My living space has helped to drive my recovery journey.(Required)Mark only one oval 1= strongly disagree - 6 strongly agree 1 2 3 4 5 6 8. I take full responsibility for my actions.(Required)Mark only one oval 1= strongly disagree - 6 strongly agree 1 2 3 4 5 6 9. I am happy dealing with a range of professional people.(Required)Mark only one oval 1= strongly disagree - 6 strongly agree 1 2 3 4 5 6 10. I am making good progress on my recovery journey.(Required)Mark only one oval 1= strongly disagree - 6 strongly agree 1 2 3 4 5 6 If you are requesting financial assistance, please summarize your needs.We are all recovering from something. How do you take care of yourself and your recovery?(Required)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
