CE Course Registration Form - Structural Competency in Peer Support

Please note that this course date has been CHANGED and will only be taught once in 2026. Instead of being taught on Weds. 10/7/2026, this course will be taught on Monday, 10/5/2026. Enrollment is limited to 20 students.

Any additional registrants will be placed on a waiting list future class dates in 2027. For more information/questions, please contact us at communityengagement@namica.org.

Question Title

1. Please enter your full legal name in the space provided. This name will be listed on your certificate of attendance. (Required.)

Question Title

2. Email Address (Required.)

Question Title

3. Phone: (Required.)

Question Title

4. Are you associated with a NAMI Affiliate? (Required.)

Yes

If Yes, please list the name of the NAMI Affiliate

Demographic Data

Question Title

5. Please select the County in California that you reside in: (Required.)

Question Title

6. Please select your age group: (Required.)

18-24

25-34

35-44

45-54

55-64

65+

Decline to Answer

Question Title

7. Which of these roles do you identify with? (Required.)

Consumer/Peer

Family Member/Loved One/Caregiver of individual living with serious mental illness

Community Leader/Organizer

State/County Employee

Prefer not to disclose

Other (please specify)

Question Title

8. Which of these best describes your Gender Identity? (Required.)

Man

Woman

Androgyne

Cisgender

Genderqueer or gender fluid

Non-binary or agender

Trans Man

Trans Woman

Questioning or unsure

Prefer not to disclose

Question Title

9. What ethnicity (ies) do you best identify with? (Required.)

American Indian/Native American/Alaskan Native

Black/African American/African

East Asian Asian (Japanese, Korean, Chinese)

Latino (Mexican, Honduran, Salvadoran, Colombian)

Latino (Guatemalan, Brazilian)

Middle Eastern

Pacific Islander (Native Hawaiian, Guamanian, Samoan, Tongan)

South East Asian (Vietnamese, Filipino/a, Laotian)

South East Asian (Thai, Indonesian, Cambodian)

South Asian (Indian, Nepali, Bangladeshi, Afghani, Bhutan)

South Asian (Pakistani, Sri Lankan)

White/Caucausian/European

Multiethnic (Please specify in the box below)

Prefer not to disclose

Unknown

If you selected Multiracial, please share those ethnicities here:

Question Title

10. Which best describes your sexual orientation? (Required.)

Straight or hetereosexual

Bisexual

Asexual

Gay

Lesbian

Pansexual

Queer

Same-gender loving

Questioning or unsure

Prefer not to disclose

Other

Question Title

11. How did you hear about this course? (Required.)

NAMI CA Website

NAMI CA Newsletter

NAMI CA State Office or Affiliate staff/volunteers

Social Media (LinkedIn, Facebook, Instagram, etc.)

County/State Agency Departments

Word of Mouth (community members, friends, family, etc.)

Other (please specify)

CE Course Registration Form - Structural Competency in Peer Support

Question Title

* 1. Please enter your full legal name in the space provided. This name will be listed on your certificate of attendance. (Required.)

Question Title

* 2. Email Address (Required.)

Question Title

* 3. Phone: (Required.)

Question Title

* 4. Are you associated with a NAMI Affiliate? (Required.)

Question Title

* 5. Please select the County in California that you reside in: (Required.)

Question Title

* 6. Please select your age group: (Required.)

Question Title

* 7. Which of these roles do you identify with? (Required.)

Question Title

* 8. Which of these best describes your Gender Identity? (Required.)

Question Title

* 9. What ethnicity (ies) do you best identify with? (Required.)

Question Title

* 10. Which best describes your sexual orientation? (Required.)

Question Title

* 11. How did you hear about this course? (Required.)

1. Please enter your full legal name in the space provided. This name will be listed on your certificate of attendance. (Required.)

2. Email Address (Required.)

3. Phone: (Required.)

4. Are you associated with a NAMI Affiliate? (Required.)

5. Please select the County in California that you reside in: (Required.)

6. Please select your age group: (Required.)

7. Which of these roles do you identify with? (Required.)

8. Which of these best describes your Gender Identity? (Required.)

9. What ethnicity (ies) do you best identify with? (Required.)

10. Which best describes your sexual orientation? (Required.)

11. How did you hear about this course? (Required.)