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NAME
ORGANIZATION NAME (If Applicable)
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STATE/COUNTRY FROM
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EMAIL ADDRESS
Special Considerations/Translation needs (closed captioning, etc.)
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How do you identify? Please select all that apply
Certified Peer Support Specialist
Certified Community Health Worker
Certified Recovery Coach
Youth Peer Specialist
Youth/Young Adult
Mental Health Consumer/Survivor/Peer
Lived experience of substance use/addiction
Latinx
Asian/Pacific Islander
African American/Black
Native American/Alaska Native
LGBTQ+
Veteran
Person with disability (PWD)
Person who has experienced homelessness
Professional
Family Member
Other
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Registration: I understand that I'll be billed via invoice to pay online a registration fee of $25. Registration fee includes access to all workshops and entry into Virtual Drawing for Door Prizes.
Yes, I agree. Please send me invoice to pay online. I understand if this fee is not paid by deadline, I'll won't get a link.
No, I don't agree. Please cancel out my registration.
I'm registering as a Peer Specialist and understand my registration fee is waived.
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While we are closing up the Planning for the 2022 Conference, are you interested in being on the Planning Committee for 2023 PEER-A-PALOOZA?
Yes, please contact me at the email above.
No, thank you.
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