QPR Registration

QPR Training Every Second Wednesday

Welcome! QPR Trainings are the second Wednesdays of every month from 11:30 am to 1:00 pm. We at NAMI Utah are delighted that you are interested in this training. For your safety we require you to complete this registration form. It will only take a few minutes.
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
How did you hear about this training?*
Email*
example@example.com
Phone Number*
Home Address*

Street Address

CityState

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

YesNo
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Gender*

MaleFemaleNon-Binary/Gender FluidAnother IdentityPrefer not to Answer
Age Group*

18-2930-3940-4950-59Over 60Prefer not to Answer
Ethnicity*

Asian/Pacific IslanderBlack/African AmericanWhite/CaucasianHispanic/LatinxNative American/Alaska NativeOther/MultiracialPrefer not to Answer
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:

QPR Training Every Second Wednesday