4/29/23 9 AM In-Person Adult Mental Health First Aid Event Registration

Thank you for your interest in attending our next In-Person Adult Mental Health First Aid Training. Please fill out this survey to get registered.

DATE: Saturday, April 29, 2023
TIME: 9:00 am - 5:00 pm
LOCATION: Williams Chapel AME Church, 1198 Glover St, Orangeburg, SC 29115
FEE: No Registration Fee
REGISTRATION DEADLINE: Wednesday, April 26th

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* 1. Do you attend a faith-based organization?

Yes

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* 2. Are you attending this training on behalf of a faith-based organization?

Yes

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* 3. Your contact info:

First Name

Last Name

Organization Name

Job Title

City

State

ZIP

County

Email Address

Phone Number

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* 4. By registering for this course, I agree to receive monthly HOTL e-newsletters, text messages and other information on other health-related issues.

Agree

Disagree

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* 5. Faith-Based Organization Demographics: Total Roster Membership

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* 6. Faith-Based Organization Demographics: Number of Active Members 18 and Older

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* 7. Faith-Based Organization Demographics: Number of Active Members Younger than 18 Years

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* 8. Faith-Based Organization Demographic Profile

Mostly European American

Mostly African American

Mostly Other

I am not representing a faith-based organization.

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* 9. Do you have any dietary restrictions? (Select all that apply.)

I do not have any dietary restrictions.

Vegetarian

Vegan

Gluten-Free

Lactose Intolerance

Other (please specify)