Wisconsin Certified Parent Peer Specialist Trainer Recertification Continuing Education Hours Report Name(Required) First Last Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone Number(Required)Email(Required) Continuing Education Hours Report Name of Event Host Agency or Conference Date of Event Speaker Name/Credentials Training Hours Topic Areas Cultural HumilityTrauma Informed CareFacilitation Skill-BuildingChild/Adolescent Development or ParentingDemonstration Facilitation Cultural HumilityTrauma Informed CareFacilitation Skill-BuildingChild/Adolescent Development or ParentingDemonstration Facilitation Cultural HumilityTrauma Informed CareFacilitation Skill-BuildingChild/Adolescent Development or ParentingDemonstration Facilitation Cultural HumilityTrauma Informed CareFacilitation Skill-BuildingChild/Adolescent Development or ParentingDemonstration Facilitation Cultural HumilityTrauma Informed CareFacilitation Skill-BuildingChild/Adolescent Development or ParentingDemonstration Facilitation Cultural HumilityTrauma Informed CareFacilitation Skill-BuildingChild/Adolescent Development or ParentingDemonstration Facilitation Cultural HumilityTrauma Informed CareFacilitation Skill-BuildingChild/Adolescent Development or ParentingDemonstration Facilitation Cultural HumilityTrauma Informed CareFacilitation Skill-BuildingChild/Adolescent Development or ParentingDemonstration Facilitation Cultural HumilityTrauma Informed CareFacilitation Skill-BuildingChild/Adolescent Development or ParentingDemonstration Facilitation Cultural HumilityTrauma Informed CareFacilitation Skill-BuildingChild/Adolescent Development or ParentingDemonstration Facilitation Cultural HumilityTrauma Informed CareFacilitation Skill-BuildingChild/Adolescent Development or ParentingDemonstration Facilitation Cultural HumilityTrauma Informed CareFacilitation Skill-BuildingChild/Adolescent Development or ParentingDemonstration Facilitation Cultural HumilityTrauma Informed CareFacilitation Skill-BuildingChild/Adolescent Development or ParentingDemonstration Facilitation Cultural HumilityTrauma Informed CareFacilitation Skill-BuildingChild/Adolescent Development or ParentingDemonstration Facilitation Cultural HumilityTrauma Informed CareFacilitation Skill-BuildingChild/Adolescent Development or ParentingDemonstration Facilitation Cultural HumilityTrauma Informed CareFacilitation Skill-BuildingChild/Adolescent Development or ParentingDemonstration Facilitation Cultural HumilityTrauma Informed CareFacilitation Skill-BuildingChild/Adolescent Development or ParentingDemonstration Facilitation Cultural HumilityTrauma Informed CareFacilitation Skill-BuildingChild/Adolescent Development or ParentingDemonstration Facilitation Cultural HumilityTrauma Informed CareFacilitation Skill-BuildingChild/Adolescent Development or ParentingDemonstration Facilitation Cultural HumilityTrauma Informed CareFacilitation Skill-BuildingChild/Adolescent Development or ParentingDemonstration Facilitation Optional Demographic Questions We ask these optional questions to gather demographics information related to those applying for recertification as CPS and CPPS. You do not have to answer these questions to submit the application. This information will not impact your ability to recertify. Age Range 18-24 25-34 35-44 45-54 55-64 65+ Highest Level of Education Completed High School or GED Some College Associate’s Degree Bachelor’s Degree Master’s Degree Doctoral Degree What describes your gender? Please check as many as apply. Man Woman Nonbinary Transgender Intersex Prefer not to say Other If you selected "Other" for gender, please specify.What pronouns do you ask others to use when referring to you? he, him, his she, her, hers they, them, theirs no pronouns (just use my name) other If you selected "Other" for pronouns, please specify.How would you describe yourself in terms of race or ethnicity? Please check as many options as apply. American Indian or Alaska Native Asian Black or African American Hispanic Latinx Native Hawaiian or Other Pacific Islander White Prefer not to say Other If you selected "Other" for race or ethnicity, please specify.Are you (or do you identify as) any of the following? LGBTQIA+ Disabled or Having a Disability Low Income Immigrant Military Veteran Formerly (or currently) Incarcerated Formerly (or currently) Homeless/Houseless Prefer not to say None of the above Other If you selected "Other" to the last question and there is any other aspect(s) of your identity or lived experience that you would like to share, please specify.Digital Signature (Type Full Name)(Required)