Mental Health First Aid Training
Registration Form
Name
*
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
*
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
Hispanic/Latino
Race
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African American
Caucasian
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Other
Date of Birth
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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.
*
September 11, 2025
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