Certified Peer Visitor Training Application

Contact and Personal Information

Training Location (City/State or Facility Name or Virtual)*

First Name*	Last Name*

Street Address*

City*	State*

Zip / Postal Code*	Country*

Email*

Mobile Phone*

Date of Birth*

Have You Ever Served in the United States Military? *

Yes

Prefer Not to Answer

Occupation*

Additional Personal Information

What Type of Individual BEST Describes You? *

If Other, Please Provide Additional Information

Are you a:*

Man

Woman

Prefer Not to Answer

Please Indicate Your Race*

American Indian or Alaskan Native

Asian or Asian American

Black or African American

Native Hawaiian or Other Pacific Islander

White

Prefer not to Answer

Please Indicate Your Ethnicity

Assistive Technology Information

What was the Cause of Your Limb Loss or Limb Difference. (Select all that apply)*

Related to diabetes complications

Related to dyvascular complications

Related to trauma

Related to congenital limb absence

Related to cancer

Related to illness

Other

Please provide more details related to the cause of your limb loss or limb difference.*

How Long have you Lived with Limb Loss or Limb Difference? (In years)*

Do You use any Assistive Devices? (Select all that apply)*

Cane

Crutches

Orthosis

Prostheses

Scooter

Walker

Wheelchair

Peer Visitor Program Questions

How did you learn about the peer visitor program? *

Are you a member of a support group? *

Yes

What skills, attributes and other experiences do you have that would be helpful in volunteering as a peer visitor? *

Please list the name of the hospitals / rehab facilities from which you will receive referrals. *

Please write a brief statement about what you expect to gain from participating in the CPV program. *

If you successfully complete the CPV course, may the Coalition share your name, level & cause of limb loss / limb difference, and contact information with: *

Your local hospitals

Your local support groups

Please don’t share my information

Background Check Information

The healthcare community often requires volunteers to pass a background check prior to having contact with vulnerable people, and our board and committees agree that this layer of professionalism and security should be offered to the people we serve. Therefore, we will run a criminal background check on all certified peer visitor candidates.

Have you ever been convicted of a crime other than a minor traffic offense? *

Yes

Does the Amputee Coalition have permission to perform a background check on you? *

Yes

I authorize investigation of all statements herein, including any checks of criminal records, and release the Coalition and all others from liability in connection with same. I also understand that misrepresentations or falsifications herein or in other documents completed or submitted by the applicant will result in dismissal, regardless of the date of discovery by the Coalition. If permission is given, you will receive an email from the Coalition with a link to Sterling Volunteers background check system within 2 weeks of application submission.

Professional Letters of Recommendation

Please submit three professional letters of recommendation (such as your prosthetist, other healthcare provider, minister, or support group leader if appropriate) by upload or email to PeerSupport@Amputee-Coalition.org. Please note that family members cannot be listed as a reference.

Please Upload Letter of Recommendation *

Please Upload Second Letter of Recommendation

Please Upload Third Letter of Recommendation

Please review your application to make sure all required fields are filled in before submitting. If required fields are missing, there will be an error message and your submission will not go through. If your CPV application is successfully submitted, you will receive a confirmation email.

If you need assistance, please connect with the Amputee Coalition’s Peer Support Department by calling 888/267-5669 or emailing PeerSupport@Amputee-Coalition.org.