CABQ QPR Gatekeeper 2022-2023
Applicant Information
10/28/2022 Friday 12:00-1:30 PM {50}
11/18/2022 Friday 4:00-5:30 PM {50}
12/6/2022 Tuesday 2:00-3:30 PM {50}
12/16/2022 Friday 8:30-10:00 PM {50}
01/12/2022 Thursday 1:00-2:30 PM {50}
02/08/2022 Wednesday 9:00-10:30 AM {50}
03/16/2023 Thursday 10:00-11:30 AM {50}
04/11/2023 Tuesday 1:00-2:30 PM {50}
05/09/23 Tuesday 4:30-6:00 PM {50}
06/08/2023 Thursday 8:30-9:30AM {50}
07/18/2023 Tuesday 3:00-4:30 PM {50}
Name
*
First Name
Last Name
Email
*
example@example.com
Work Phone
*
Please enter a valid phone number.
Do we have permission to send a text to your mobile phone if we are having difficulty contacting you via email?
*
Yes
No
Mobile Phone
*
Please enter a valid phone number.
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
My shipping address is:
The same as above
Different than above
Shipping Address (CAN NOT BE A PO BOX)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Demographic Information
Age
17 and Under
18-24
25-34
35-44
45-54
55-64
65+
Your gender:
Female
Male
Transgender
Self-Identify
Please indicate your race/ethnic identity below (you may check more than one)
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Black or African-American
White or Caucasian
Hispanic or Latino
Other
What is your military status?
I am currently serving on active duty in the U.S. Armed Forces
I am a veteran of the U.S. Armed Forces.
I have never served in the U.S. Armed Forces
Do you have a spouse, child, sibling, guardian, or parent currently serving on active duty in the U.S. Armed Forces?
Yes
No.
Do you have a spouse, child, sibling, guardian, or parent who is a veteran of the U.S. Armed Forces?
Yes
No.
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Professional Information
Position Title
Organization/Institution
Select all that apply to you:
Administrator
Behavioral Healthcare Professional
Community Member
Emergency Responder
Faith Community
Government Agency
Healthcare Professional
Higher Education
Military Member or Family
Private School
Public/Charter School
School-Based Health Center (SBHC)
School Counselor
School Nurse
Social Worker
Student/Youth
Teacher
Therapist/Counselor
Youth-Serving Organization
Other
How did you hear about this training?
Word of Mouth
Email
Social Media
Work
School
Other
Are you multilingual?
Yes
No
Please list the languages you are fluent in below:
What are your current training certifications?
How will this training benefit you?
How will attending this training benefit New Mexico schools and adolescents?
Briefly describe how you plan to utilize the training content in your work:
Briefly describe how this training supports your organization/institution policies and procedures:
Does your supervisor support your attendance to this training? (All applicants will be considered, but applicants with supervisor support will receive priority.)
Yes
No
N/A - I do not have a supervisor
Supervisor's Full Name
Supervisor's Email
Supervisor's Phone Number
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Training Accommodations
Please indicate if you require special accommodations:
Yes
No
As part of my scholarship to this training, I understand that I will be asked to report my own training data to the NM Department of Health, Office of School and Adolescent Health at three, six and 12 month intervals.
*
I understand and agree to the statement above.
As part of my scholarship to this training, I understand that I will be asked to report my own training data to the NM Department of Health, Office of School and Adolescent Health at three, six and 12 month intervals.
Clear
Submit
Should be Empty: