Cape Cod Community College: Addiction Recovery Coach Pre-certification and Wellness Training (ARC)

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* 1. Please provide the following contact information.

First Name:

Last Name:

Mailing Address:

City/Town:

State:

Zip Code:

Phone Number (best number to contact you):

Alternate Phone Number (if applicable)

Email Address:

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* 2. Date of Birth

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* 3. Gender

Female

Male

Prefer not to say

Other (please specify)

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* 4. Race (mark all that apply)

Asian

Black or African American

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

White

Other (please specify)

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* 5. Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Other (please specify)

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* 6. Do you identify as having military or Veteran status?

Yes

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* 7. Do you receive Supplemental Nutrition Assistance Program (SNAP) benefits and/or TANF/TAFDC? (check all that apply)

SNAP Benefits

TANF/TAFDC

Not Applicable

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* 8. Please select the highest level of schooling that you have completed.

Less than 9th grade

9-12 grade, no diploma

High school diploma

GED/high school equivalency

Some college, no degree

Associate's degree

Bachelor's degree

Master's degree and above

Other post-secondary education (please specify)

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* 9. What is your current employment status?

Employed Full-Time (35+ hours per week)

Employed Part-Time (Less than 35 hours per week)

Unemployed

Other (please specify)

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* 10. Where do you currently work?

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* 11. What is your job title?

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* 12. This program was developed and designed for individuals in recovery (with at least 9 months of sobriety) and individuals with lived experience.

I certify that I have at least 9 months of sobriety and/or lived experience.

Other (please specify)

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* 13. This program requires motivation and self-discipline, as you will be required to work both independently and online. Are you comfortable being in an online learning environment?

Yes

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* 14. Are you in need of a laptop to participate in this program? (student loaner laptops may be available to those in need)

Yes

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* 15. Do you have direct experience in the field of recovery and/or support services?

Yes

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* 16. If you have direct experience, briefly describe your work experience.

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* 17. If you do not have direct experience, do you have related experience you would like to share?

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* 18. Specifically, what attracts you to pursuing the Addiction Recovery Coach credential?

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* 19. Why do you want to participate in this program?

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* 20. What do you hope to gain from your participation in this program?

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* 21. How did you hear about this opportunity?

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* 22. Two Letters of Reference Required: We are grateful that we have once again been entrusted with grant funds to offer our Addiction Recovery Coach Pre-certification and Wellness Training Program. To help us make informed choices in our selection process, we're asking you to submit two letters of reference prior to acceptance: one letter from a character reference and another letter from a performance reference (paid or volunteer work or student/program participant). Email both letters using your full name in the email subject line to smcleod@capecod.edu or mail letters to: Cape Cod Community College, Hyannis Center, Attn: Steve McLeod, 540 Main Street, Hyannis, Ma 02601.

I understand that two letters of reference are required for my application to be considered.

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* 23. Disclaimer: By typing my name below, I am signing this application electronically. I agree that my electronic signature is the legal equivalent of my manual signature on this application. I hereby certify and attest that the information stated above is true and accurate. I acknowledge that the information on this application may be used for evaluation purposes by Cape Cod Community College, Massachusetts Department of Higher Education, and Massachusetts Association of Community Colleges.