1st Aid Youth Virtual

Date Selected *

I am 18 years old or older. *

Yes No

We cannot accept your registration unless you are 18 years old or older.

It appears that you did not come to this form from the Plumas Rural Services website.

To ensure your registration is accurate please go to the following link and select the date you wish to register for.

www.plumasruralservices.org/1staid

You are registering for the class to be held from JANUARY 20, 2021 from 9:30am to 3:30pm.

Participants must be 18 years of age or older.

This class will be held online using Zoom.

2HR ONLINE SELF-PACED TRAINING MUST BE COMPLETED BEFORE ATTENDING THE VIRTUAL INSTRUCTOR LED TRAINING. INFORMATION PROVIDED AFTER REGISTRATION.

Name *

First Name Last Name

Company Name

Position

Email *

example@example.com

Phone Number *

Area Code Phone Number

1) How did you hear about this event? *

Flyer Social Media Email

2) Do you belong to any of the following groups? Please mark all that apply. *

Veteran Veteran’s Family Member/Caregiver College Student School Staff (e.g., teacher, aide, professor, coach, administrator, support staff, child care provider, etc.) First Responder (e.g., law enforcement, fire fighter, emergency medical, etc.) LGBTQ+ Other (Specify below)

Please specify "Other"

3) I understand that this course is funded by a SAMHSA Mental Health Awareness Training grant and is provided at no cost to participants. I understand that there is a requirement for the grantee (Plumas Rural Services) to collect data following the course to determine the effectiveness of the training and how it has been implemented. For this training, the data collection includes completing a short quarterly follow-up email survey (1-5 minutes to complete). I understand that this is voluntary and my decision to participate or not will not affect my access to services, including training.

Agree to Survey *

Yes, I understand and will commit to completing a quarterly survey Other (Specify below)

Please Specify "Other"

4) I understand that during this training we will be discussing topics and sharing experiences related to different aspects of mental health, including suicide. I understand that these topics could prompt some psychological and emotional reactions or distress for me such as anxiety, sadness, anger and grief; I understand that support and resources will be available to me should I require it.

Acknowledge Support and Resources *

Yes, I understand Other (please specify below)

Please specify "Other"