Thank you for your interest in attending our next In-Person Adult Mental Health First Aid Training. Please fill out this survey to get registered.

DATE: Saturday, July 18, 2026
TIME: 9:00 am - 5:00 pm
LOCATION: James E. Holiday Fellowship Hall Bushy Pond Baptist Church
1396 Wire Rd. Norway, SC 29113
FEE: No Registration Fee
REGISTRATION DEADLINE: Wednesday, July 8, 2026

*1.Do you attend a faith-based organization?(Required.)

Yes

No

*2.Are you attending this training on behalf of a faith-based organization?(Required.)

Yes

No

*3.Your contact info:(Required.)

First Name

Last Name

Organization Name

Job Title

City

State

AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming

ZIP

County

Email Address

Phone Number

*4.By registering for this course, I agree to receive monthly HOTL e-newsletters, text messages and other information on other health-related issues.(Required.)

Agree

Disagree

5.Faith-Based Organization Demographics: Total Roster Membership

6.Faith-Based Organization Demographics: Number of Active Members 18 and Older

7.Faith-Based Organization Demographics: Number of Active Members Younger than 18 Years

8.Faith-Based Organization Demographic Profile

Mostly European American

Mostly African American

Mostly Other

I am not representing a faith-based organization.

*9.Do you have any dietary restrictions? (Select all that apply.)(Required.)

I do not have any dietary restrictions.

Vegetarian

Vegan

Gluten-Free

Lactose Intolerance

Other (please specify)