Certified Peer Visitor Training Application

Please complete all required fields on this CPV application that are marked with an *. If your CPV application is successfully submitted, you will receive a confirmation email.

Contact & Personal Information

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

Your Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Work Phone

Email*

Birthdate*

Please enter a valid date in the format (mm/dd/yyyy).

Gender*

Specify Unlisted Gender

Preferred Pronouns

Have you ever served in the United States Military?*

Yes
No

Branch of Service*

Occupation

Race/Ethnicity*

American Indian or Alaska Native
Asian
Black/African American
Caucasian/White
Pacific Islander
Spanish/Hispanic/Latino(x)
Race/ethnicity not listed
Prefer not to answer

Specify Race/Ethnicity*

Languages spoken (other than English)

Are you a...*

Person living with limb loss or limb difference
Family caregiver

Amputation Information

Because you indicated that you are a person living with limb loss or limb difference, please supply the following information about yourself. Online forms cannot be submitted without the required fields. If you need assistance, please call 888/267-5669.

Date of limb loss

Please enter a valid date in the format (mm/dd/yyyy).

Type of Limb Loss/Limb Difference*

Select all that apply.

Specify Type of LImb Loss/Limb Difference

Because you selected Not listed above, please indicate here.

Amputation Level*

Select all that apply.

Unilateral
Bilateral
Trimembral
Quadrimembral

Cause(s) of Limb Loss/Limb Difference*

Select all that apply.

Specify Cancer Indication

Specify Congenital Indication

Specify Disease Related Indication

Specify Infection Indication

What was the cause of the trauma?

Other Cause

Because you selected Not listed above, please indicate here.

Assistive Devices*

Select all that apply.

Cane
Crutches
Prosthesis
Scooter
Stubbies
Walker
Wheelchair
Other

Other Assistive Devices

Because you selected Other above, please indicate here.

Other Considerations & Additional Information

Vision Impairment
Hearing Impairment
Use of support animal
Other

Other additional information (specify)

Because you selected Other above, please indicate here.

Peer Visitor Program Questions

How did you learn about the peer visitor program?*

Are you a member of a support group?*

Yes
No

Support Group Name

Support Group Leader

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

Background Check:
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
No

If yes, please explain:*

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

Yes
No

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 provide three professional letters of recommendation (such as your prosthetist, other healthcare provider, minister, support group leader if appropriate). Family members cannot be listed as a reference.

File Upload*

Upload your files or send them by email to peersupport@amputee-coalition.org

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 3 MB, Max. files: 3.

CAPTCHA

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.

Phone

This field is for validation purposes and should be left unchanged.

Advertise With Us

Advertise With Us

Connect With Us!

Enter your search terms below.

Certified Peer Visitor Training Application

Contact & Personal Information

Amputation Information

Peer Visitor Program Questions

Professional Letters of Recommendation