Mental Health First Aid Training
Registration Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Street Address
*
City
*
State
*
Zip Code
*
County of Residence
*
Ethnicity
*
Non-Hispanic/Latino
Hispanic/Latino
Race
*
African American
Caucasian
Asian
Hispanic
Other
Date of Birth
*
-
Month
-
Day
Year
Date
Position/Affiliation
*
Academic Institution
Prevention Research Center Staff
Community Member
Student
Government Employee
CECAN Member/Community Partner
Community Health and Preventative Medicine (CHPM) Staff
Community Health Worker (CHW)
Other
Organization
*
Choose the date you would like to attend.
*
July 9, 2025 (Virtual Session)
August 6, 2025 (Virtual Session)
September 3, 2025 (Virtual Session)
October 4, 2025 (In-Person Session in North GA; ***More details coming soon)
Submit
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