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 Quantity:
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
Card Number Expiration Date Security Code Cardholder Name

Name (first & last)	email address

Your Information