Teen Mental Health First Aid Interest Form

1

Student's Name* This field is required.

First Name

Last Name

2

Student's Age* This field is required.*This course is only available to teens in 10th-12th grades OR ages 15-18

3

Current Grade Level in School?* This field is required.*This course is only available to teens in 10th-12th grades OR ages 15-18

4

Is the student enrolled in a High School in BIBB COUNTY (Macon, GA)?* This field is required.

YESNO

5

What school does the student attend?* This field is required.If the student is not enrolled in school, please type "N/A" for your answer

6

In which format would the student rather take the course?* This field is required.

In-person

Virtual

7

Is the student is available to dedicate 1 hour per week for 6 weeks to complete this course?* This field is required.

YESNO

8

If the student chose the IN-PERSON class format, does the student have transportation to and from the class each week?* This field is required.

Yes

No

Student did NOT choose in-person

9

If the student chose the VIRTUAL class format, does the student have transportation to and from the class each week?* This field is required.

Yes

No

Student did NOT choose Virtual

10

Is a parent/guardian willing to attend a brief informational session about the Teen Mental Health First Aid Program?* This field is required.

YESNO

11

What is your best contact phone number?* This field is required.

12

What is your best email address?* This field is required.

13

Almost done! Please click SUBMIT!