NAMI CA Event Registration Survey

Thank you for your interest in a NAMI CA event.

We appreciate you taking the time to answer some questions about yourself and your interest in NAMI CA. We will ensure to keep your responses private and secure. All of the responses will be anonymous and only seen and used by NAMI CA staff. NAMI CA will not be using this information for discriminatory purposes. This information will be used for data collection for NAMI CA reporting. Please complete the full survey and click done at the end of the survey to submit. Once this is completed, NAMI CA will send you a link to register for your event within 1 to 2 business days.

For any questions, please contact nami.california@namica.org.

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* 1. Which event are you registering for?

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* 2. What is the date for this event?

Date

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* 3. Please answer the following questions:

What is your first name?

What is your last name?

What is your email?

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* 4. Please select the county you reside in:

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* 5. Please select your age range.

14-18 Years

19-24 Years

25-34 Years

35-44 Years

45-54 Years

55-64 Years

65+ Years

Prefer not to disclose

Unknown

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* 6. Which race(s) do you best identify with? You may select multiple answers. (Race options below were determined by the US. Census Bureau)

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White or Caucasian

Prefer not to disclose

Unknown

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* 7. Which ethnicity(ies) do you best identify with? You may select multiple answers.

American Indian/ Native American/ Alaskan Native

Black/ African American/ African

East Asian (Japanese, Korean, Chinese)

Latino (Mexican, Honduran, Salvadoran, Colombian, Brazilian, Guatemalan)

Middle Eastern

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

South Asian (Indian, Nepali, Bangladeshi, Afghani, Bhutan, Pakistani, Sri Lankan)

South East Asian (Vietnamese, Filipino/a, Laotian, Thai, Indonesian, Cambodian)

White/ Caucasian/ European

Multiracial (Please select mutiple ethnicities above if known)

Unknown

Prefer not to disclose

Other (please specify)

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* 8. Which of these describe your gender idenitity(ies)? You may select multiple answers.

Androgyne

Cisgender

Demigender

Genderqueer or gender fluid

Non-binary or agender

Man

Questioning or unsure

Queer

Trans man

Trans woman

Woman

Prefer not to disclose

Other (please specify)

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* 9. Which of these describe your sexual orientation(s)? You may select multiple answers.

Asexual

Bisexual

Gay

Straight or heterosexual

Lesbian

Pansexual

Queer

Questioning or unsure

Same-gender loving

Prefer not to disclose

Other (please specify)

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* 10. Please select any other identities and backgrounds that you would like to share with us. You may select multiple answers.

Transitional age youth (TAY) (16-25)

Veteran

Person experienced/ing current or former foster youth

Person experienced/ing immigration

Person with disability

Person experienced/ing homelessness

Prefer not to state

Not applicable

Other (please specify)

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* 11. Please state your NAMI affiliate (if applicable) (i.e: NAMI Amador, NAMI Monterey, NAMI Urban LA)

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* 12. Which of these roles do you identify with? You may select multiple answers.

Consumer/Peer- Individual living with mental health condition(s)

Family member/ Loved one/ Caregiver of an individual living with mental health condition(s)

Medical Provider

Mental Health Care Professional

Student/ Youth

Education/ Educator

Faith Leader

Community Leader/ Organizer

Advocate/ Community Stakeholde3r

State/ County Employee

Community/Non-profit Organization Leader or Staff

Prefer not to disclose

Other (please specify)

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* 13. How did you hear about/ were informed about this event?

NAMI California email

NAMI California website

Other NAMI California event

Flyer

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

NAMI staff/volunteers

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

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* 14. Are you interested in participating in local and/or state advocacy work with NAMI CA?

Yes. If so, please register for upcoming events at https://namica.org/events/

No, thank you

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* 15. Are you interested in receiving communications from NAMI CA about upcoming events and activities?

Yes. If so, please sign up for our newsletter at https://namica.org/newsletter/

No, thank you

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* 16. I acknowledge to receive the Zoom information for the 2022 NAMI CA Youth Mental Health Conference I will have to complete the registration by following the link provided after submitting this survey.

Yes

I am not registering for the 2022 NAMI CA Youth Mental Health Conference.