Mental Health First Aid Training
Registration Form
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Street Address
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City
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State
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Zip Code
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County of Residence
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Ethnicity
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Non-Hispanic/Latino
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Race
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African American
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Date of Birth
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Month
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Day
Year
Date
Position/Affiliation
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Academic Institution
Prevention Research Center Staff
Community Member
Student
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CECAN Member/Community Partner
Community Health and Preventative Medicine (CHPM) Staff
Community Health Worker (CHW)
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Organization
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Choose the date you would like to attend.
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Thursday, April 16, 2026 (9:00AM - 2:30PM)
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