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Program Leader Application Form

Training Details: If your application is accepted, you will be invited to participate in the next available training. Some programs also contain an online training element in addition to the in-person training. Pay close attention to any and all emails received pertaining to your training. You can reference our State Training page for information on upcoming trainings such as dates, location, lodging, etc.

NAMI Affiliates/ Participants are responsible for travel and lodging expenses. Candidates must have the support of their local NAMI Affiliate in order to apply. If you do not know your local NAMI Affiliate, you can consult our Find Your Local NAMI page. If you are having trouble contacting your affiliate, or are still unsure please email education@namikeystonepa.org for assistance.

PLEASE NOTE: Completion of an application does NOT certify you as a NAMI Program Leader nor does it guarantee you a position at a NAMI State training. NAMI Keystone Pennsylvania reserves the right to determine an applicant's eligibility at any time before or during the training process based on their responses on their application and/or their performance during the training process. All information collected on this form is confidential and will not be used for solicitation purposes. Applicants and their endorsing affiliates will be contacted by NAMI Keystone Pennsylvania's Education Department if their application is accepted.

Please select the NAMI Program which you would like to volunteer for:*

If you wish to apply for more than one NAMI program, please specify the other programs here:

Personal Information

First Name*

Last Name*

Street Address*

City*

State*

Zip Code*

Home Phone

Cell Phone

Email Address*

Anyone interested in becoming a NAMI Program Leaders must have the endorsement of their local or nearest NAMI affiliate. If you are unsure what NAMI affiliate is local to you or how to contact them, you can always visit our Find Your Local NAMI page to find an affiliate near you. If you wish to become a NAMI Program Leader in the Allegheny County area or are having difficulty contacting your local or nearest affiliate to secure an endorsement, please contact our education department at education@namikeystonepa.org or toll free by phone 1 (888) 264-7972.

Please provide the name of the AFFILIATE endorsing you:*

Please provide an EMAIL ADDRESS for your affiliate contact:*

Please provide the FULL NAME of your primary contact at this affiliate:*

Availability & Suitability

Are you a current NAMI member?*

Yes No

Are you you an individual (18+) who is currently or has experienced a mental health condition?*

Yes No

Are you a family member/loved one of an individual (18+) who has a mental health diagnosis?*

Yes No

Are you willing to attend a training for your specified NAMI Program and are you prepared to run the program according to NAMI policy?*

Yes No

Do you have a computer capable of video conferencing such as Zoom?*

Yes No

If 'Yes", are you willing to run your specified program virtually?

Yes No

Are you fluent in a language other than English?*

Yes No

If 'Yes', please specify which other languages you are proficient in:

Questionnaire

Why do you wish to be a NAMI Program Leader or Presenter for your specified program:*

What personal attributes do you possess that you feel will benefit you as a NAMI Program Leader or Presenter: (Please include both personal and/or professional experience with mental health)*

Please describe what the term "recovery" means to you as it pertains to mental health.*

Have you ever been convicted of a felony?*

Yes No

If 'Yes', please specify:

Volunteer Agreement

I have read and understood the requirements for a Program Leader or Presenter of the NAMI program I specified and feel that I can meet those requirements.*

True False

I agree to attend the training on time and attend the entire training. In the event that I cannot attend the training, I will notify the NAMI Keystone PA Education Department as soon as possible (education@namikeystonepa.org):*

True False

I acknowledge that all presenter/training materials and handouts are protected by copyright and I will not copy or distribute without permission of the copyright holder.*

True False

I understand that my attendance at training does not guarantee that I will be certified as a NAMI Program Leader or Presenter.*

True False

After I have become certified, I agree to lead or present the NAMI program I specified at least once in the year following the completion of my training.*

True False

Emergency Contact Information

Emergency Contact First Name*

Emergency Contact Phone*

Emergency Contact Last Name*

Emergency Contact Email Address*

Thank you!

Thank you for registering for Family to Family! You will be contacted soon regarding course availability and to confirm your registation.

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