NAMI Georgia SIGNALS Teacher Training Application NAMI Georgia SIGNALS Teacher Application Please submit this form to register for a NAMI SIGNALS Teacher training session. Applicant Name* First Middle Last Suffix Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*Phone*Alternate PhoneEmail* Special Dietary Needs(Vegetarian, allergy, kosher, diabetic, etc.)Emergency Contact*NamePhone Have you ever been convicted of a felony?*YesNoGive explanationHave you ever attended a NAMI educational course?*YesNoCourses AttendedCourse TypeTeacherLocationStart Date Please give information on NAMI courses which you have attended. (Family to Family, HomeFront, Basics, SMARTS for Advocacy).Are you a trained instructor/presenter for any other NAMI signature educational program? NAMI Family to Family NAMI Ending the Silence NAMI Basics Other OtherMembership StatusAre you currently a NAMI member?*YesNoAffiliateMembership Expiration Date Date Format: MM slash DD slash YYYY Anyone who requests to be trained to lead a NAMI program must be a current member, and to continue to lead or teach, they must keep their membership current Join NAMI QualificationsPlease describe your experience as a youth development stakeholder (i.e. pediatric professional, parent, educator, etc)*Why would you like to become a NAMI Georgia SIGNALS Teacher?*Code of Conduct*Please provide an example of how you have and will demonstrate the following NAMI Signature Program Leader Code of Conduct requirement: Remain accountable for your own behavior and keep personal opinions and actions separate from those made as a representative of NAMI. Understand that your actions and behaviors reflect on the integrity of NAMI signature programs and impact the public perception of NAMI as an organizationPlease acknowledge your agreement to each of these requirements:* I will obtain approval from the State Program Director at least 6 weeks in advance with class location/dates/co-teacher details so that the class can be advertised on the NAMI National and NAMI Georgia web sites. NOTE: Co-teacher must also be certified to teach SIGNALS. NAMI State Program Director will determine if this class meets the requirements stipulated by NAMI Georgia. I will teach my first class as soon as possible after my training (No more than 4 months after training). I will recertify every two years. (NAMI Teachers/facilitators serve under the auspices of their affiliate, and must be approved each year by the affiliate board, with notice sent to NAMI GA of the approval). I understand that this application and my attendance at SIGNALS Training does not guarantee that I will be certified as a NAMI SIGNALS Teacher. If I complete this training and receive certification as a NAMI SIGNALS Teacher, I will teach at least two SIGNALS classes within a two year period. I have read, understand and agree to abide by the terms and conditions outlined in the NAMI Signature Program code of conduct and the NAMI Signature Program Operating Policies. I fully understand that violating any of the conditions outlined in either the NAMI Signature Program Code of Conduct or the NAMI Signature Program Operating Policies 2016 may result in the termination of my role as a NAMI Signature Program Educator, Facilitator, Mentor, Presenter, Trainer or any other role designated as a leadership role in any of NAMI’s Signature Programs. I agree to follow proper protocol, policies, procedures and the NAMI Georgia chain of command and will conduct myself in a professional manner, representing NAMI Georgia in the most positive light at all times. CAPTCHAPersonal Privacy Agreement*Please check this box to confirm that you will abide by our personal privacy requirement. I agree not to divulge any information concerning any individual to any unauthorized person without the written consent of the individual, or guardian of the individual, or parent or court-appointed custodian of a minor individual, as applicable.