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safeTALK T4T Application Form

Course date: 12 & 13 May 2010 APPLICATION DEADLINE: April 30, 2010
Time: 8:00 - 5:00 pm
Training location:
Doubletree Castle Hotel,
Orlando, Florida,
Instructor: Wallis Balog
Course fee: $400.00 US (regular cost around $700.00)

All safeTALK trainers need a high-speed internet connection and computer with QuickTime or Windows Media Player to access files and updates.
Course fee includes lunches and nutribreaks, T4T study material and the safeTALK Trainer Kit. Note that the slides in the kit are digital. A television with DVD player OR a computer with a DVD player, projector and external speakers are required to do safeTALK trainings once you have completed the safeTALK T4T.
The optional, customizable trainer material on DVD-ROM is available for an additional cost of $50.00.
Candidates are responsible for transportation and accommodations.
Please be aware that if attending a contracted T4T, your employer may be notified of your instructor's recommendations.

Fill out the form below and click the "Apply Now" button once, or print and fax it to +1 (403) 209-0259. An asterisk (*) indicates required fields. Please notify webmaster@livingworks.net if you experience any technical difficulties using this form. In the event that a course is cancelled, payment will be refunded in full.

Statement of Principles

I have taken an ASIST two-day workshop or I am an ASIST trainer.

ASIST workshop date:
Location (city or military base):
Trainer(s):

I have read and embrace the fundamental assumptions about suicide outlined in Essential Information for safeTALK Trainer Candidates.
If I wish to use the customizable materials, I am an experienced computer user or I can obtain access to computer technical support on my own.
I read well and I am an experienced presenter. I am willing to work hard to become a safeTALK trainer.
I am attending a two-day T4T. I have read the training schedule, and I understand that in addition to the time at T4T, LivingWorks estimates that another 16 hours of post-T4T preparation will be required to prepare for my first training.
I appreciate the importance of scheduling my first safeTALK before attending my T4T.
I understand that LivingWorks reserves the right to make final decisions regarding my potential to become a trainer. I also understand that a history of unresolved participant complaints can serve as a basis for removal from the list of registered trainers. Trainer materials need to be returned in either of these circumstances.
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 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 are recommended and that some regional agreements may modify these freedoms.
I recognize that I need to complete three trainings within the first year to receive my trainer certificate with at least one of those being done on my own without another trainer and complete two trainings per year thereafter to maintain my trainer status.
I understand that I must make my name or trainer number available to participants so that they can determine that I am a trainer.
I know that the current cost of a safeTALK Resource Kit can be found at www.livingworks.net.
I understand that safeTALK is a standardized program with customizable options and that I must present it consistent with its manual and any approved options.
I know that safeTALK trainer and participant materials are copyrighted and as such may not be abridged, altered, extracted, or presented in a manner inconsistent with the standard procedures without written permission from LivingWorks Education.

* I agree to the above Statement of Principles, as does my employer (if applicable).

Contact Information

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.

*Name in full (as it should appear on certificates):	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:
State/Prov:		Zip/Postal Code:
Country:		*Home Phone (with area code):
Home Fax:		*Home E-mail:

WORK

Organization:
Department:		Your Title:
Work Address:		City:
State/Prov:		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 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.

Options and Payment

To order the customizable trainer material for PowerPoint on DVD-ROM (includes library of alternative video clips and the flexibility to customize slides and select which co-trainer clips to include), please indicate:
($50.00)
I would like to attend the conference after this pre-conference :
($300.00)
Special dietary requirements:
Special onsite needs concerning mobility, audio or visual accessibility:

*Payment is due in full at time of application.

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

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

Last updated March 15, 2009