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Program Interest Form

Intervention Request Information

1. Are you filling out this form on behalf of yourself or another person(s), agency, or civic group? (If other please, specify) *This question is required.

Please enter an 'other' value for this selection.

2. What program or training are you interested in registering for or wish to receive more information? (Select all that apply) *This question is required.

Mental Health First Aid Training (Youth and Adults)
Question, Persuade, Refer Training
CODE RED Training
988 Material Request
Source of Strength - (For K-12 Institutions)
Narcan Training
PAVe Parent Presentation - E-cigarette Education
On Young Minds - Community Presentation
CATCH MY BREATH - Community Presentation
CATCH MY BREATH - Train the Trainer (For K-12 Institutions)
Too Good For Drugs Curriculum (K-12 Institutions)
Dinner Table Boxes (Parents/Guardians)
Tobacco Free Policy (Technical Assistance)
Tobacco Treatment - Group Clinic(s)
Medicine Lock Boxes (Limit = 50)
Medicine Disposal Pouches (Limit = 50)
Data Request
Other - Write In (Required) Please enter an 'other' value for this selection. * This question is required.

3. Approximately, when would you like to receive training, or host the event. *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

4. What time would you like to have the event/presentation/training? *This question is required.

5. Who is the majority of your audience? Select all that apply. *This question is required.

K-12 Students
Young Adults (12-26 yrs.)
Civic Group or Organization
First Responders (EMS, Fire, Police)
Parent or Guardians - School Aged Youth
Recovery Organization or Support Group
Church Congregation
Business - Staff
Other - Write In (Required) Please enter an 'other' value for this selection. * This question is required.

6. Approximately how many people will be in attendance? *This question is required. This question requires a valid number format.