MHFA Instructor Program Mental Health First Aid Instructor Program Application Question Title * 1. Applicant's Name Question Title * 2. Contact Information Email Work Phone Cell Phone Question Title * 3. Library System where you are currently employed: Question Title * 4. Do you have the approval of your Library Director and/or immediate supervisor to become a Mental Health First Aid Instructor? Yes No Question Title * 5. Is your Library Director and/or immediate supervisor aware of the required commitments for you to become a Mental Health First Aid Instructor? Yes No Question Title * 6. After completing the 5-day Instructor Training, to maintain your certification as a Mental Health First Aid Trainer you are required to conduct three 8-hour trainings. Do you feel confident that you have the ability to be a trainer?** Yes No Question Title * 7. Have you provided professional trainings before? Yes No Question Title * 8. If you have provided professional trainings before, please provide a brief description of the training, your role, the target audience and the intended outcomes of the training? Question Title * 9. Give a brief description for why want to become a Mental Health First Aid Instructor? Question Title * 10. How long have you been working for your current employer? Question Title * 11. How long do you plan to continue working for your current employer? Question Title * 12. Please identify which of the Mental Health First Aid Instructor Trainings is your first choice and which is your second choice. 1 2 San Diego - September 19 - 23, 2016 1 2 Sacramento - October 24 - 28, 2016 Question Title * 13. By submitting this application, type yes in the boxes if you agree to the completing the following requirements: Attending all 5 days of the Mental Health First Aid Instructor Training Providing three 8-hour Mental Health First Trainings by June 2017 Applications are due no later than close of business day (5:00 pm PST) on August, 19, 2016. **More than two or more people can team up to conduct a training and each will receive credit for one training. Done