CE Course Registration Form - Structural Competency in Peer Support

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

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* 2. Email Address

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* 3. Phone:

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* 4. Are you associated with a NAMI Affiliate?

Yes

If Yes, please list the name of the NAMI Affiliate

Demographic Data

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

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* 6. Please select your age group:

18-24

25-34

35-44

45-54

55-64

65+

Decline to Answer

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

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)

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

Man

Woman

Androgyne

Cisgender

Genderqueer or gender fluid

Non-binary or agender

Trans Man

Trans Woman

Questioning or unsure

Prefer not to disclose

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

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:

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* 10. Which best describes your sexual orientation?

Straight or hetereosexual

Bisexual

Asexual

Gay

Lesbian

Pansexual

Queer

Same-gender loving

Questioning or unsure

Prefer not to disclose

Other

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* 11. How did you hear about this course?

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)