Mental Health First Aid Course Registration Form
Name
*
First Name
Last Name
E-mail
*
Confirmation Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you identify as any of the following?
Please Select
Under 21 years of age
An adult who has direct and continuous contact with students
A private school employee
Attorney
Judge
Employee of a licensed Childcare Facility
911 Dispatcher
EMS/Paramedic
Fire Department Employee
Police/Sheriff Department Employee
None of the above
Please choose one
Are you a Veteran, Service Member, or Family to one?
*
Yes, I am a Service Member
Yes, I am a Veteran
Yes, I am a Family Member
No, I am not a SMVF
Do you have any food allergies or restrictions?
*
Submit
Should be Empty: