REST Trainer Event Application

All fields required unless otherwise noted.

Trainer Information

Which training are you interested in attending?

Organization
Occupation
First Name
Last Name

Email Address

Street Address
City
State
Zip Code
Phone

How did you hear about the REST Program?

Trainer Background

How much experience do you have training?

NoneSomeTrain Often

Do you currently work with individuals who provide respite?

YesNo

Once you become a REST trainer, do you know at least 20 individuals you could offer the REST training to?

YesNo

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?

YesNo

If yes, please explain:

Trainer Profile

Primary Spoken Language:

EnglishSpanishOther (please specify)

Other primary spoken language (if applicable)

Preferred Spoken Language

EnglishSpanishOther (please specify)

Other preferred spoken language (if applicable)

Hearing Status

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)

HispanicNot Hispanic

Race (for informational purposes only - optional)

White/CaucasianAmerican Indian/Alaskan NativeAfrican/African AmericanNative Hawaiian/Other Pacific IslanderAsian/Asian AmericanMultiracialUnknown