Name *

First Name

Last Name

Phone

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

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Required for certification as a PSS in Adult Addictions *

Check All That Apply

I identify as a person in recovery from an addiction

I have one year of recovery experience or longer

I identify as a person in recovery from problem gambling or other addicitons

Attending for my personal growth - Certificate of Participation only will be awarded

I understand that payment in full must be received before the training begins and training must be completed before a Certificate of Completion is issued. No refunds if training is not completed. Cancelation prior to two weeks before training subject to $50 cancelation fee; no refunds if canceled less than two weeks prior to beginning of class. *

Agree