Youth Mental Health First Aid Name* First Last Title/RolePhone*Agency (please put NONE if unaffiliated)*Email* PhoneAddress* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code I reside in Arizona*YesNoAre you a behavioral health care provider ?*yesnoSpecial Populations served by me/my agency, please check all that apply* Faith Community Youth Elderly LGBTQ Veterans Other (Please specify below) Please specify otherI understand (please check all)* In order to be certified by MHFA/YMHFA I am required to attend the entire workshop and pass the Participant Quiz (6/10) The Self-Paced portion of the training must be completed in order to participate in the live/virtual session I will be sent three online surveys after I complete Mental Health First Aid I will receive a gift card incentive for my participation in the surveys Participant acknowledgment (initials)Date Date Format: MM slash DD slash YYYY Please select session* Wednesday, April 21, 9-3pm Wednesday, May 12, 9-3 pm Tuesday, May 18, 9-3pm Wednesday, June 9, 9-3 pm Wednesday, June 23, 9-3 pm Wednesday, July 7, 9-3 pm Wednesday, July 21, 9-3 pm CAPTCHA