Mental Health First Aid Customized Class Request: Instructors are available on a limited basis to provide custom Mental Health First Aid classes.

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* 1. Contact Name

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* 2. Organization (if applicable)

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* 3. Contact Email address

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* 4. Contact Phone number

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* 5. I am interested in setting up a

Adult Mental Health First Aid Class (English)

Youth Mental Health First Aid Class (English)

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* 6. I am requesting a two day format. Schedule the 2 sessions no more than a week apart. (Please allow a minimum of 30 days notice.)

Date / Time

Date

Date / Time

Date

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* 7. I am requesting a one day format. (Please allow a minimum of 30 days notice.)

Date / Time

Date

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* 8. A class must have a minimum of 10 and may have a maximum of 25 participants (space permitting). Note that participants must be 18 years or older.

We can provide at least 10 participants.

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* 9. Can you provide training space? (The class requires room for separate tables of four to five participants each with enough room to move around.)

Yes, we have adequate training space for the class.

No, we will need assistance finding adequate training space.

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* 10. Several pieces of equipment are needed for the training. Please indicate which you can provide:

LCD Projector

Laptop with Office 2010 or better

Speakers

We cannot provide equipment. Please bring your own.