Parent & Teen Mental Health Conference Participant Registration

Please Complete ONE Registration Form PER HOUSEHOLD.

Fill in your information below and select SUBMIT to secure your place at Herkimer County System of Care's Parent & Teen Mental Health Conference!

You will receive an email with further event information.

Thank you!

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* 1. Main Contact Name:

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* 2. Main Contact Phone Number:

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* 3. Main Contact Email Address:

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* 4. Number of Parents/Caregivers Attending:

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* 5. First & Last Name of Parent/Caregiver #1 Attending:

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* 6. First & Last Name of Parent/Caregiver #2 Attending (if applicable):

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* 7. Number of Teens (Age 13-19) Attending:

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* 8. First & Last Name(s) of Each Teen Attending:

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* 9. Name of Teen(s)' Home School District

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* 10. Food Restrictions

Yes

If Yes, please specify

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* 11. Is this your/your family's first time attending a mental health conference?

Yes

If no, share with us!

Parent & Teen Mental Health Conference Participant Registration

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* 1. Main Contact Name:

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* 2. Main Contact Phone Number:

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* 3. Main Contact Email Address:

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* 4. Number of Parents/Caregivers Attending:

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* 5. First & Last Name of Parent/Caregiver #1 Attending:

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* 6. First & Last Name of Parent/Caregiver #2 Attending (if applicable):

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* 7. Number of Teens (Age 13-19) Attending:

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* 8. First & Last Name(s) of Each Teen Attending:

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* 9. Name of Teen(s)' Home School District

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* 10. Food Restrictions

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* 11. Is this your/your family's first time attending a mental health conference?

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* 12. What is ONE thing you hope to take from this conference?