EmailMe Form - Family-to-Family Teacher Training, June 3-5

Select Affliate Name: *
If an outside affiliate, affiliate name:
Teacher Application
Please complete the following information and submit as instructed to ensure your application is accepted. Submission of an application does not guarantee attendance.

Providing your preferred contact information will simplify communication now and for future national, state and local Family-to-Family teacher records.
Name of individual for training: *
First Last
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Phone preference: *
### - ### - ####
Email *
If from an outside affiliate, candidates must have the approval of either the affiliate president or executive director. Registrants should also be current NAMI members with preference for graduates of a Family-to-Family class unless your affiliate has not been able to offer the class on a regular basis.
If you are not a member or need to renew, dues are $35 for individual/family or $3 for indivuals with limited resources. You may join at online using a credit card or by contacting your local affiliate. NAMI membership revenue is distributed to NAMI National, NAMI Florida and your local affiliate.
*

Yes No

Are you a member of your local NAMI affiliate?

Have you taken the Family-to-Family course?
Name and contact information of affiliate president or executive director: *
Qualifications:
Prospective teachers must be family members or partners of individuals living with mental illness.
What is your relationship to the individual living with a mental illness. *
What is the age of that individual now? *
*

Yes No

Has he or she been given a diagnosis?
Please indicate why you would like to be a Family-to-Family teacher: *
This box is limited to 300 words.
Agreement:
I understand that all NAMI programs are copyrighted.

I will adhere to the NAMI Program Policy's Code of Conduct(as linked here) and teach according to the policies outlined in the course materials.

I understand teachers are expected to teach 2 classes as determined by their affiliate.
*

Yes No

I am in agreement with the above terms.
Training Logistics:
Accomodations and lodging:
We have negotiated a block of hotel rooms at Home2 Suites by Hilton, 210 S. Magnolia Drive, Tallahassee 32301, which is within walking distance of the training site or a 5 minute drive.

NAMI-Tallahassee registrants should indicate their room preferences. Those who wish a private room will be expected to share the cost of the room or split the $100 per night fee.

Other Affiliate Registrants are encouraged to take advantage of the reduced rate of $100 per night by calling 850-402-8900 and asking for the NAMI group rate. Reservations must be received by 05/09/2016, after that date rooms at the reduced rate will be released.
NAMI-Tallahassee candidates only: Please check those boxes which apply.

Friday night Saturday night Prefer private room

Queen Suite

Double Suite

Do not book me a room, I prefer to commute the following nights.
Please list any special needs (dietary, accessibility, etc.):
If we need to contact you, please give us let us know which days and times are most convenient for you. *
Thank you for responding. We will follow-up with confirmation. Please feel free to contact Pat Stephens at 850.544.4522 if you have specific questions.
Date Time *
MM / DD / YYYY

	Yes	No
Are you a member of your local NAMI affiliate?
Have you taken the Family-to-Family course?

	Friday night	Saturday night	Prefer private room
Queen Suite
Double Suite
Do not book me a room, I prefer to commute the following nights.

	Yes	No
Has he or she been given a diagnosis?

	Yes	No
I am in agreement with the above terms.

Teacher Application

Qualifications:

Agreement:

Training Logistics:

Thank you for responding. We will follow-up with confirmation. Please feel free to contact Pat Stephens at 850.544.4522 if you have specific questions.