Mental Health First Aid

Acworth United Methodist Church Mental Health First Aid Registration: August 13th, 10am-3:30pm

Please Note: There is pre-course work that MUST be completed prior to training.
Name

First Name Last Name
E-mail
Phone

Area Code Phone Number
Organization or Congregation
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
How old are you?

18-20 years 21-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65-74 years 75 years and older
Gender

Female Male Other/Unknown
Ethnicity

Hispanic or Latino Not Hispanic or Latino
How would you describe yourself?

American Indian/Alaskan Native Asian Black/African-American Native Hawaiian/Pacific Islander White or Caucasian Multiracial/More than one Race Other/Unknown
Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans, such as Medicare or Indian Health Service?

Yes No
Would you say that, in general, your overall health is . . .

Excellent Very Good Good Fair Poor
Please Note:

I understand that there is pre-course work that I must complete virtually prior to attending the in-person training.
Should be Empty:

Acworth United Methodist Church Mental Health First Aid Registration: August 13th, 10am-3:30pm