All fields required unless otherwise noted.
Which training are you interested in attending?
---September 2017 - Getzville, NYSeptember 2017 - Kingston, NYOctober 2017 - Malone, NYOctober 2017 - Albany, NYOctober 2017 - Lander, WYNovember 2017 - Reno, NVJanuary 2018 - Boynton Beach, FL
How did you hear about the REST Program?
---WebsiteFamilyFriendEmailSocial MediaFaith Community
How much experience do you have training?
Do you currently work with individuals who provide respite?
Once you become a REST trainer, do you know at least 20 individuals you could offer the REST training to?
Through what network would you offer the respite training?
My OrganizationFaith CommunityOther (please specify below)
Other network (if applicable):
What population do you serve?
Developmentally DisabledAgingVetsOther (please specify)
Other population (if applicable):
Do you have funding resources for respite training?
If yes, please explain:
Primary Spoken Language:
EnglishSpanishOther (please specify)
Other primary spoken language (if applicable)
Preferred Spoken Language
Other preferred spoken language (if applicable)
I am hearing.I am deaf/hard of hearing.
Need for interpretation services
Not needed.American Sign Language (or other form of sign language needed)Foreign Language interpretation services neededOther (please specify below)
Other interpretation service required (if applicable):
Ethnicity (for informational purposes only - optional)
Race (for informational purposes only - optional)
White/CaucasianAmerican Indian/Alaskan NativeAfrican/African AmericanNative Hawaiian/Other Pacific IslanderAsian/Asian AmericanMultiracialUnknown