CPSS Registration1 | SPARK

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SPARK CPSS Training Registration

Welcome to the Certified Peer Specialist class presented by SPARK Peer Learning Center in collaboration with Washington State Health Care Authority. We are excited to join you on your journey to becoming a Certified Peer Specialist.

Please answer the questions on this form in order to complete your registration.This is an 80-hour hybrid (in-person & virtual) class.

Details of the training as are follows:

In-Person Portion

Location:

Dates:

Time: 8am to 5pm

Online Portion

Dates:

Time: 8am to 12pm

Training Location Your Registering For (IMPORTANT: You must select the training location HCA has invited you to)*

Legal Last Name*

Legal First Name*

Preferred Name

Preferred Pronouns

Personal E-mail (Required for Exam)*

Work E-mail (As a Backup)

Phone Number (The best one to for us to reach you at)

Address (For Exam Purposes)

Country/Region*

Address*

City*

Zip / Postal code*

Agency You Work For (If Applicable)

Job Role (If Applicable)

Are there any reasonable ADA accommodations you may require for training and/or testing?

Would you prefer a vegetarian lunch option?*

Yes

No

Are there any other allergies/restrictions we should be aware of? (Please type None if you do not have any)*

Please read and acknowledge: Lunch and all required materials will be provided by SPARK

Please read and acknoweldge: Transportation and Lodging are the responsibility of the participant or employer

Please read and acknowledge: The personal e-mail address that you provide will be used for any future communication and shared with the testing proctor for the purpose of your written test and exit interview

Please read and acknowledge: We understand that childcare may be a barrier, but children are not allowed in the class. Please be sure to arrange childcare as needed prior to joining the class.

Please read and acknowledge: Participants must attend the entire training. Attendance is monitored and during the online portion, cameras are required to be turned on.

Please read and acknowledge: A participant may only have 30 minutes of unexcused absence, or 3 hours of authorized absence during the in-person portion of the class. If absence exceeds this allowance, the participant may not continue the class.

Please read and acknowledge: A participant may only have 30 minutes of unexcused absence, or 3 hours of authorized absence during the virtual portion of the class. If absence exceeds this allowance, the participant may not continue the class.

Please read and acknowledge: Please let SPARK know if you need any kind of accommodation

Will you require your service animal?*

Yes

No

Please read and acknowledge: An online written exam and an exit interview will be conducted after the training by a testing proctor. Specific testing times will be scheduled during training.

Please complete this form only once. You will receive a confirmation letter within a week

If you have questions or need to contact us, please reach out to the following people:
Diana: dmccallum@wayouth.us
Matt: mpolley@wayouth.us

Thank you

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