Student Interest Form CADC

Please fill out the form below carefully. This starts your screening process and acceptance process. After submitting the form, either you will be contacted by a CI representative or you will receive an email with instructions to register within one business day. Please make sure your telephone number and email address are correct.

STUDENT INTEREST FORM CPC

* Indicates required field

Name *

First

Last

Email *

Retype email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Why do you want to become a certified Prevention Specialist *

Describe your experience, if any, in the field substance abuse counseling or helping others. *

Do you have at least a H.S. Diploma or Equivalency *

Yes No

Check if you are 18 or over. *

Yes

Comments and/or questions *

Submit

STUDENT INTEREST FORM CPC

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STUDENT INTEREST FORM CPC