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ASIST Training for Trainers Application Form

Reminder: All canddates must read Essential InfoFill out the form below and click the "Apply Now" button once. An asterisk (*) indicates required information. A non-refundable deposit of $500.00 is require to reserve a seat on any T4T training. In the event that a course is cancelled, any payments will be refunded in full. You can also print and fax this form to +1 (403) 209-0259.

Course Dates: June 7-11, 2010
Location: Holiday Inn Bordeaux
1707 Owen Drive
Fayetteville, North Carolina
28311
Block of rooms under LivingWorks (Jerry and Dale Swanner- organizer)

Course fee: Consider what presentation equipment you will be using to facilitate your ASIST workshops. Will you use PowerPoint slides (standard inclusion with every trainer kit), or will overhead transparencies also be required? If overhead transparencies are not required, course fee is reduced and your trainer kit will be lighter and easier to handle. If you find you need transparencies at a later date, they can be ordered from LivingWorks at any time (shipping charges will apply).
WITHOUT overhead transparencies in trainer kit: $2550.00 USD (plus tax where applicable)
WITH overhead transparencies in trainer kit: $2600.00 USD (plus tax where applicable)

Course fee includes: Refreshments, lunches, ASIST trainer kit (trainer manual, organizer guide, implementation guide, workshop audiovisuals, posters, slides, dissemination materials, carrier bag and suicideTALK, a program for providing awareness presentations. NOTE: Please bring your laptop if possible.

Statement of Principles

  1. I have read the Essential Information for Candidate Trainers and understand the commitments that will be asked of me as a trainer.
  2. I have had time to consider my decision, to discuss it with my employer, and I have freely chosen to participate.
  3. I understand that the training materials I will receive can only be used by those who have successfully completed the five-day T4T course. My employer is aware that the training materials I will receive become my property, regardless of who pays my course fees.
  4. I must punctually attend all five days of the T4T course or risk having to retake the course.
  5. I need to work onsite either Wednesday or Thursday evening of the course.
  6. I should avoid any other commitments during the week as almost every waking hour is required for the course.
  7. I read well. I am a hard worker. I already have or I am willing to work hard to develop strong presentation and small group facilitation skills, and an understanding of the scientific literature on suicide.
  8. I recognize that completing three workshops within the first year will establish my Registered status and presenting one workshop per year thereafter will maintain my Registered status. I also know that I will need considerable preparation time for my first few workshops.
  9. I recognize that material pricing for ASIST is subject to change and is kept current on LivingWorks' website.
  10. I understand that this course prepares me for edition X of ASIST. Edition 6 and edition X trainers cannot work together to do an ASIST workshop.
  11. I understand that workshops should be conducted in a safe workplace setting.
  12. I appreciate that in the interest of maintaining standards, LivingWorks has the right to observe workshops that trainers present.
  13. I recognize that each individual trainer has the right to decide such implementation issues as marketing, prices and trainer fees although agreements among trainers in a region is recommended.
  14. I understand that I will need to arrange for the payment of the services of a Consulting Trainer should I be required to use them after T4T as part of the process of becoming a trainer.
  15. I understand that LivingWorks reserves the right to make final decisions regarding my potential to become a trainer. Only some portion of the materials costs is returned in those rare circumstances where a candidate is not authorized to continue in the process of becoming a trainer.

* I agree to the above Statement of Principles

Contact Information

LivingWorks will keep the information you provide here on file, along with your photograph (taken at the course) for the purpose of confirming your identity, recording training history and credits, collecting dissemination statistics, providing service and support and sending internal communications and completion certificates. You can update your information at any time by contacting LivingWorks’ main office. LivingWorks maintains a high level of security with respect to the confidentiality of your records. We do not collect information that is extraneous to the efficient operation of LivingWorks, nor do we release contact information without your authorization. See LivingWorks’ Privacy Promise at www.livingworks.net.

*Your Name in Full (as it should appear on Certificates of Completion): M     F 
In what other languages could you serve as a trainer?
If you have worked with special populations, please specify knowledge/experience:

HOME

Home Address: City:
Prov/State:
Zip/Postal Code:
Country: *Home Phone (with area code):
Home Fax: *Home E-mail:

WORK

Organization:    
Department: Your Title:
Work Address: City:
Prov/State: Zip/Postal Code:
Country: Work Phone (with area code):
Work Fax:
Work E-mail:

*Which address should we use to contact you? HOME    WORK

The network of trainers and session leaders registered with LivingWorks Education is a key source for sharing resources and supporting suicide-safer communities. Your contact information will be available to this network unless otherwise indicated here: Please do not release my contact information to other registered trainers and session leaders

Payment and Options

*COURSE FEE:
$500 USD deposit now due (non-refundable unless course is cancelled or postponed) with balance due by start of course. Term is net 30 days.

  Please note we are currently working on implementing a secure online payment system. At this time, to speed up order processing please phone or fax your credit card information to Phone: +1 (403) 209-0242 or Fax: +1 (403) 209-0259. Your applicaton will be invoiced after receiving your credit information.

VISA   MasterCard
Check
Check Number:
Mail check(s) payable to:
LivingWorks Education
4303D 11 Street SE
Calgary, Alberta T2G 4X1
OR
 
Covered by Organization
P.O. #:
(Available from your organization)
Organization:

*SPECIFY AUDIOVISUAL FORMAT (for the workshop videos in the trainer kit): DVD   VHS     PAL DVD   PAL VHS

DIETARY AND ONSITE REQUIREMENTS
Refreshments and lunches are included. Please let us know of any special dietary requirements:
Please specify any special onsite needs concerning mobility, audio or visual accessibility:

 

(Click button ONCE. If you do not receive a confirmation within two business days, contact LivingWorks)    

     Last updated February 23 2010