Community Members age 51+ Focus Group Registration Form

We invite you to take part in a focus group to discuss your views and experiences regarding suicide prevention and cultural components to strengthen identity within Native American youth. This meets the grant award requirements for the Reach UR Life program with Native Americans for Community Action. This focus group is for community members 51 and over age range. We welcome everyone within Coconino, Apache, and Navajo County, from all professions and experiences to sign-up! We require all participants to sign-up prior to the focus group as the group is limited to 10 people.

Each participant may only participate once and receive one gas card.

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1. Name: (Required.)

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2. Email: (Required.)

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3. Phone (optional):

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4. Company/Organization:

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5. I understand that in order to get a $50 incentive gas card, I must stay for the entirety of the 60-90 minute focus group. Please select one option only. (Required.)

I understand and will be in attendance for the entire group.

I may need to leave, but will stay for at least 95% of the group.

I cannot guarantee that I will stay and am ok with not receiving a gas card if I leave the group prior to 60 minutes.

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6. The focus group topic is centered on cultural outlook on mental health and ways to create strategies and insight for youth in hopes to help families address mental health for prevention efforts.

I understand.

Any comments or concerns?

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7. I am 51 years old or older, and live in Coconino, Apache, or Navajo County. (Required.)

Yes

Community Members age 51+ Focus Group Registration Form

Question Title

* 1. Name: (Required.)

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* 2. Email: (Required.)

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* 3. Phone (optional):

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* 4. Company/Organization:

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* 5. I understand that in order to get a $50 incentive gas card, I must stay for the entirety of the 60-90 minute focus group. Please select one option only. (Required.)

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* 6. The focus group topic is centered on cultural outlook on mental health and ways to create strategies and insight for youth in hopes to help families address mental health for prevention efforts.

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* 7. I am 51 years old or older, and live in Coconino, Apache, or Navajo County. (Required.)

1. Name: (Required.)

2. Email: (Required.)

3. Phone (optional):

4. Company/Organization:

5. I understand that in order to get a $50 incentive gas card, I must stay for the entirety of the 60-90 minute focus group. Please select one option only. (Required.)

6. The focus group topic is centered on cultural outlook on mental health and ways to create strategies and insight for youth in hopes to help families address mental health for prevention efforts.

7. I am 51 years old or older, and live in Coconino, Apache, or Navajo County. (Required.)