NAMI UT Course Registration Form

Course Registration Form

Welcome! We at NAMI Utah are delighted that you are interested in our online courses. For your safety we require you to complete this registration form. It will only take a few minutes.
Today's Date *

Month Day Year
Date
Name *

First Name Last Name
How did you hear about NAMI Utah's online courses? *
Peer-to-Peer: 8 week course for individuals with mental health conditions.

Family-to-Family: 8 week course for family members and loved ones of those with mentalhealth conditions.

Basics: 6 week course for parents of children 18 and younger with mental health conditions.
Please choose the session you would like to attend. *

Peer-to-Peer Course: Starting TBA Family to Family Course: Starting TBA Basics Course: Starting September 14th
Age Group *

18-30 30-40 40-50 50-60 Over 60
Email *
example@example.com
Phone Number *

Area Code Phone Number
Home Address *

Street Address

City State

Zip Code
Affiliate/County *
If you experience an emergency during a class would you like us to contact someone? *

Yes No
If yes, who should we contact? (name AND phone number)
I understand that NAMI programs are confidential unless teachers believe I am in danger of hurting myself or someone else. If a teacher is worried about my safety they will contact the crisis unit and my emergency contact. I realize this is to protect me and keep me safe: *
(Initial)
I give NAMI Utah permission to send me emails (I can opt out at a later time): *
(Initial)
Should be Empty: