Registration Form for Certification in Recovery from Racisms

Name: __________________________________ Phone: (____)________________

Address: ________________________________ Fax: (____)___________________

City, State Zip ________________________________

Each level of certification builds upon the Personal Recovery Training. Facilitating Focal Support Groups includes the Personal and Task Group Training. Please check the level of training that you are registering for.

______ Personal Recovery Training $100.00 (10 hours)

______ Facilitating Task Groups for Recovery $150.00 (15 hours)

______ Facilitating Focal Support Groups for Recovery $250.00 (30 hours)

1) If applicable, what organizational/institution is sponsoring your participation?

        _____________________________________________________________________

2) How do you plan to use the information and formation from this training in your professional and/or personal life?

        _______________________________________________________________________________

        _______________________________________________________________________________

        _______________________________________________________________________________

        _______________________________________________________________________________

Make checks to: IRR (Institute for Recovery from Racismsâ )

Send Registration to: IRR Registration

The Lyke Center

P.O. Box 13559

Detroit, MI 48213

For more information call: 313-521-7777 x 2

Upon receipt of your registration, hotel information will be sent along with background materials.