CAPPA Teen Educator Training

Thank you for your interest in attending the CAPPA Teen Educator Training. To complete your registration, please fill out the information below.

Name (as it should appear on your certificate)

Date of Birth

Age

Title and Organization

Training date and location:

Address 1

Address 2

City

State

Postal Code

Phone

Alternate Phone

Email Address

Re-enter Email Address

Website

Please list professional affiliations, if any.

Please describe your experience in working with pregnant/parenting teens.

What is your background as a childbirth and/or sex education instructor?

Why would you like to become a teen educator?

What do you hope to learn from this training?

Briefly describe your education and training.

Please choose one of the following:

I plan to complete the traditional certification.

I do not plan to certify.

CAPPA Membership:

I am currently a CAPPA member and will bring proof of membership to the training

I will become a CAPPA member prior to the training, and will bring proof of membership to the training

I do not plan to certify as a Teen Educator with CAPPA (membership is only required if you are seeking certification)

How did you hear about this training? (can choose more than one)

TERMS AND CONDITIONS

By submitting this registration form, I agree to the following terms and conditions:

I understand that I am not registered for this training until I have completed this registration form AND my training payment has been received by Kay Miller.
I understand that there are no refunds for the training but I can transfer to another training with Kay Miller within 12 months of the original course date with written approval from Kay Miller.
I understand that I must pay for my training in full at least 30 days before the training (unless other arrangements have been made with Kay Miller).
I understand that I should not make non-refundable travel reservations until Kay Miller has confirmed the workshop 21 days prior to the course.
I understand that CAPPA membership, the Teen Educator Certification Packet, and the Processing Fee are not included in the cost of the training.
I understand that I must be a member of CAPPA should I choose to seek certification as a Teen Educator with CAPPA. (You can obtain membership at www.cappa.net)
I understand that I must purchase a CAPPA Teen Educator Certification Packet to complete my certification.
I understand that I must pay CAPPA a Processing Fee when my certification materials are sent in.
As a participant of this training, I agree to allow Kay Miller/CAPPA to do the following:
- Publish my name, address, phone number, and email address for the trainee class list & referral list.
- Take photographs of the training which may include me, as well as allow the trainer and CAPPA to use these photographs for promotional purposes online and in print.
- Use quotes from my training evaluations (which I may fill out anonymously) for promotional purposes online and in print.
I understand that I may not record the training workshop (audio or video). I may take photographs only with the express permission of the trainer and the other participants.
I understand that I may not reproduce, publish, or distribute any materials in the training manual.
I understand that I may not reproduce, publish, or distribute any materials from the certification packet, other than for the purpose of fulfilling my certification requirements (i.e. copying the evaluation forms for my clients to fill out)
I understand that this course is only the first step in becoming a CAPPA Certified Teen Educator. There are several other steps that I must complete after the training in order to be eligible for certification by CAPPA.
I understand that I must attend all days of the training. If I miss any portion of the training, I will not receive a certificate of completion and/or CEUs.
I understand that I will receive an email confirmation from Kay Miller within 48 hours of submitting this form. If I do not receive that confirmation, I will contact Kay Miller at heavensentsupport@gmail.com to ensure that the registration was received.

I verify that all of the information given in this registration form is true. I further affirm that by filling out this online registration form and by typing my name in the box below, I agree to the terms as given herein, and my electronic signature is in lieu of my physical signature.

Electronic Signature:

Indicates Response Required