safeTALK Training for Trainers Registration Form

NOTE: This course has an online pre-session study component. A high-speed internet connection and computer with QuickTime or Windows Media Player is required. The safeTALK Trainer Kit (includes training slides and manual) is distributed at the T4T on DVD. There is no printed material.

Fill out the form below and click the "Register Now" button once. An asterisk (*) indicates required information. You can also print and fax this form to +1 (403) 209-0259. In the event that a course is cancelled, payment will be refunded in full.

Course Date: May 14, 2008
Time: 8:00 am - 5:00 pm
Training Location:
Sheraton Park South Hotel
9901 Midlothian Turnpike, Richmond, VA. 23235
Instructor: Jerry Swanner - usa@livingworks.net or (910) 867-8822
Total cost of training: $425.00 USD
safeTALK Trainer Kit, pre-session study material, lunches and nutri-breaks. Candidates are responsible for their own transportation and accommodations.

REGISTRATION DEADLINE: Apr 16, 2008.

Statement of Principles

I have read the Essential Information for safeTALK Trainer Candidates and understand the commitments that will be asked of me as a trainer.
I have had time to consider my decision, to discuss it with my employer, and I have freely chosen to participate.
I read well. I am a hard worker. I already have or I am willing to work hard to develop strong presentation skills. I will increase my understanding of the scientific literature on suicide.
I embrace the fundamental assumptions about suicide illustrated in the Essential Information for safeTALK Trainer Candidates.
I recognize that completing three trainings within the first sixth months will establish my registered trainer status and presenting two trainings per year thereafter will maintain my registered status. I also know that I will need considerable preparation time for my first few trainings. I appreciate the importance of scheduling my first safeTALK before completing my safeTALK Training for Trainers course.
I understand that safeTALK is a standardized program with customizable options and that I must present it consistent with its manual and the approved options.
I recognize that material pricing for safeTALK is subject to change and is kept current on LivingWorks' website.
I understand that safeTALK trainings should be conducted in a physically and emotionally safe environment that includes a community support resource who is either ASIST trained or has suicide intervention skills.
I appreciate that in the interest of maintaining standards, LivingWorks has the right to observe trainings that trainers present.
I recognize that each individual trainer has the freedom to decide such implementation issues as marketing, prices and trainer fees. I understand that agreements among trainers in a region is recommended and that some regional agreements may modify these freedoms.
I understand that I may be required to access additional support from an instructor after my safeTALK Training for Trainers course. I know that I have to arrange for the payment of this support if it is required.
I understand that LivingWorks reserves the right to make final decisions regarding my potential to become a trainer. Only the materials costs can be 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

Payment is due in full at time of registration

VISA MASTERCARD	Card Number:
	Cardholder's Name:
	Expiry Date:
OR
Check	Check Number:
Check	Check Number:	Mail check(s) payable to: LivingWorks Education Inc. 4303D 11 Street SE Calgary, Alberta T2G 4X1

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)