NAMI Connection Support Group Facilitator Application NAMI St. Louis Connection Application Name* First Middle Last Please provide your first, middle, and last name. 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 Email PhoneAlternate Phone NumberSocial Secuirty Number - Required for Background Check*Date of Birth - Required for Background Check* Date Format: MM slash DD slash YYYY Have you been a speaker, teacher, mentor or support group facilitator for NAMI St. Louis before?*YesNoI have been a speaker, teacher, mentor, or support group leader for another NAMI Affiliate.If you have been a speaker, teacher, mentor or support group leader before, which program and where was it located?*Have you attended a NAMI Connection support group before?*YesNoAre you currently a member of NAMI St. Louis?*YesNoWhat type of Membership do you prefer? (You are required to be a member of NAMI St. Louis to become a support group leader.*Household - $60Individual - $40Open Door - $5Are you willing to complete all paperwork/reports required by NAMI St. Louis?*YesNoHow often are you able to facilitate a support group?*Once per monthTwice per monthWeeklyHave you ever been convicted of a felony? If yes, please explain.*Describe in 3-5 sentences why you would like to become a support group facilitator.*Describe in 3-5 sentences your experience with mental health conditions.*Describe in 3-5 sentences your work/volunteer experiences and / or qualifications.*Describe in 3-5 sentences the dates, times, locations that you are available to hold a support group.*Reference Name* First Last Reference Phone Number*Reference Email*Do you have any accommodation requirements or special dietary needs?*Connection Recovery Facilitator Requirements* I am willing to undergo training to become a NAMI Connection support group leader.Connection Recovery Facilitator Requirements* I am willing to adhere to the fidelity of the NAMI Connections support group model.Connection Recovery Facilitator Requirements* I am can make a commitment to facilitate a NAMI Connection support group for at least one year.Connection Recovery Facilitator Requirements* I am willing to identify potential new facilitators from my support group.Connection Recovery Facilitator Requirements* I have a positive regard for, or personal experience with, mutual support.Connection Recovery Facilitator Requirements* I am a member of am willing to become a member of NAMI St. Louis.Connection Recovery Facilitator Requirements.* I understand that my attendance at Facilitator Training does not guarantee that I will be certified as a NAMI Recovery Support Group Facilitator.Consent* I have read and agree to the following volunteer policy.I expect to be informed of in-service training opportunities. I expect to be informed of job descriptions and supervisors for specific volunteer tasks. I hold harmless from liability NAMI St. Louis and its staff for any injury which might occur during volunteer activities. I give consent for background checks as deemed necessary for volunteer activities. I understand that I may seek assistance from the Outreach Specialist if problems arise in the performance of my volunteer duties which I cannot resolve with the staff.