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PRSS Mentorship Application Form
Thank you for expressing interest in our PRSS Mentorship program! In order for us to get to know you better, we need you to answer a few questions for us.
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Name
*
Your answer
Phone number
*
Your answer
Email
*
Your answer
Date of birth? (mm/dd/yyyy)
Your answer
What gender do you identify with?
Male
Female
Transgender
Nonbinary
Other:
Clear selection
Race
White or Euro-American, Non-Hispanic
Black, Afro-Caribbean, or African American
Latino or Hispanic American
East Asian or Asian American
South Asian or Indian American
Middle Eastern or Arab American
Native American or Alaskan Native
Other:
Clear selection
Are you a veteran?
Yes
No
Prefer not to say
Clear selection
Have you ever been convicted of a felony? If so, what were the charges and in what year were you convicted?
*
Your answer
How long have you been in recovery?
*
Your answer
What does recovery mean to you?
*
Your answer
Why do you want to pursue a PRSS certification?
*
Your answer
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