SAM Training Registration Form - April 2026

Registrant Information

Full Name*

First Last

Photo Permission*

I agree for ECR to use any photos of me from the training for promotional materials.

County*

Address*

Street Address City State ZIP Code

Email Address*

Phone Number*

Phone Type*

Cell
Land Line

County JDAI Coordinator's Name (If Known)

If you are a student/faculty/staff at Manchester University or a resident of Wabash County, do you wish to apply for a full scholarship to cover the cost of the training?

Scholarships are awarded to qualified participants who sign a contract agreeing to do 15 Wabash County SAMs over a period of 2 years.

Yes
No
Not Applicable

Check all that apply:*

MU Student
MU Faculty
MU Staff
Wabash County Resident
None of the above

Training fee for ECR SAM mediator certification (all sessions must be attended for certification)*

Price:

Payment Options*

Pay via PayPal (including 3% processing fee)
Pay by check (send by March 27, 2026, to ECR, PO Box 275, North Manchester, IN 46962)

PayPal Fee*

Price: $0.00

Registration Total

$0.00

Registration Total
Applied for Scholarship. We will be in touch after you register.

Notes

Phone

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

SAM Training Registration Form – April 2026

April 2026 School Attendance Mediation (SAM) Training Registration Form

Registrant Information

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NEED RESOURCES?

What Is Our Philosophy?

WHY SUPPORT US?