Youth Mental Health First Aid Registration

Youth Mental Health First Aid

• Name*
  First Last
• Title/Role
• Phone*
• Agency (please put NONE if unaffiliated)*
• Email*
• Phone
• Address*
  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*
  YesNo
• Are you a behavioral health care provider ?*
  • yes
  • no
• Special Populations served by me/my agency, please check all that apply*
  • Faith Community
  • Youth
  • Elderly
  • LGBTQ
  • Veterans
  • Other (Please specify below)
• Please specify other
• I 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