Mental Health First Aid Registration

General registration form for all MHFA trainees, regardless of date.

Affiliation
In what capacity are you attending the training?
Training Date You Plan to Attend*
Please select the training date you plan on attending ** Please note that not all training dates are available to community members. **
Other: describe

In what "Other" capacity are you attending?
Your Information
Name*
First Last
Email*
Company
Work Phone*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
A brief description of why you're enrolling in the course.
(Examples: help family member or loved one, better serve clients/public with mental health issues, seeking general mental health information)
Multiple participants
Name (first & last) email address

If registering mulitple participants please list all participants names and emails.
Payment Information
Registration Fee*
Price: $20.00
Training starts at 10:00am and runs to 2:30pm at the Lines for Life office (5100 SW Macadam Avenue, Ste. 400, Portland)
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

Name (first & last)	email address

Your Information