ASIST Fall 2020

Date Selected

Age. *

Under 16 years old 16 or 17 years old 18 years old or older

We cannot accept your registration unless you are 16 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/asist

You are registering for the class to be held from June 29th & 30th, 2020 from 8:30am to 4:30pm.

Participants must be 16 years of age or older.

The class will meet at:

Christian Life Fellowship Church

317 1st Street

Quincy, CA

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 Youth (under 18 years old) 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+

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"

Your response to "Age" and selections in question #2 do not match. Please review and correct your responses.

A Parental Consent form will be emailed to you as an attachment upon the completion of this registration. Please ensure the form is completed and signed by your parent/guardian.

The form can be sent to:

Email: tmasters@plumasruralservices.org

Fax: (530)283-3647 (Please send to the attention of Tammy Masters)

Drop Off or Mail:

Plumas Rural Services

711 East Main Street

Quincy, CA 95971

If you or your parent/guardian have any questions, please call (530)283-2735 ext. 882

This message will be included in the return email once this registration is submitted.