REGISTRATION FORM

Please answer all questions truthfully.  All of your answers will be kept strictly confidential and never associated with your name.

Address

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* 1. Address

Please identify your affiliation

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* 2. Please identify your affiliation

If you are a family member what is your relationship to the child, teen, or adult with a disability or mental illness?

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* 3. If you are a family member what is your relationship to the child, teen, or adult with a disability or mental illness?

What are barriers to the treatment of disabilities or mental illness?

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* 4. What are barriers to the treatment of disabilities or mental illness?

Are you seeking continuing education credits?

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* 5. Are you seeking continuing education credits?

If yes, what type?

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* 6. If yes, what type?

Do you need accommodations?

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* 7. Do you need accommodations?

Do you need a scholarship?  

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* 8. Do you need a scholarship?  

Are you interested receiving a monthly newsletter or e-mail updates from Emerging HOPE?

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* 9. Are you interested receiving a monthly newsletter or e-mail updates from Emerging HOPE?

If yes, please type your first and last name, mailing address, and e-mail below:

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* 10. If yes, please type your first and last name, mailing address, and e-mail below:

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