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Professionals in Residence Participant Application 5 Day Program

There is a fee and deposit required for this program to reserve a date. Travel and hotel information will be sent or faxed to you with your confirmation information.

Please Complete The Following:

First Name:
Middle Name:
Last Name:
Occupation:
Employer:
Education:
Business Address:
City:
State:
Zip:
Business Phone:
Business Fax:
Home Address:
City:
State:
Zip:
Home Phone:
Cellular Phone:
E-mail Address:

Contact In Case Of Emergency:

Name:
Relationship:
Address:
City:
State:
Zip:
Telephone:


Are you studying or working in the chemical dependency field?
     
yes no


What involvement do you have with chemical dependency?
Personal Professional
Please Explain:


Previous training in the chemical dependency field:


What specific information would you like to obtain from the
professional in residence program?


How do you think you you will integrate this experience into your professional life?


2010 Session dates are as follows: Please indicate your session date preference below.
January 4 - January 8
January 25 - January 29
February 1 - February 5
February 8 - February 12
February 15 - February 19
February 22 - February 26
March 29 - April 1
April 12 - April 16
May 24 - May 28
June 21 - June 25
July 19 - July 23
August 16 - August 20
First Choice:
Second Choice:
Third Choice:
Fourth Choice:
Fifth Choice:
Sixth Choice:
Seventh Choice:
Eighth Choice:


Acknowledgment of the following statements is required:

  1. It is my understanding that my Professional in Residence (PIR) session dates are to be arranged upon receipt of this application.
  2. I understand this information is confidential and will be kept on file.
  3. I understand that the experience provided by this program includes attendance in group therapy and other sessions which may be emotionally charged and I assume responsibility for any personal issues which may arise as a result thereof.
  4. I understand that this program is experiential, neither training nor counseling.
  5. I acknowledge that the PIR program is a 5 day commitment and I will arrange my travel and work schedules so that I am able to participate from 7:30am on Monday through the 3:00pm Friday conclusion of the week.
  6. I understand that the program fee and a deposit is required to reserve a date.
  7. To the best of my knowledge, the information contained in this application is true. I understand the participation requirements.



______________________________________________
Signature if sending application


The information collected in this form is encrypted and sent to us through a secure server. We have taken all reasonable measures to protect the confidentiality of your information. However, no one can give absolute assurance that your information will remain secure, and normal risks exist that third parties may intrude on the server and view your information. By pressing the SUBMIT button you agree that you are aware of those risks and choose to send this information. If you do not wish to submit your information electronically, you may print this form and mail it to:

Betty Ford Center Training Department
39000 Bob Hope Drive
Rancho Mirage, CA 92270
or fax it to: (760) 773-1508
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