NAMI Multnomah · NAMI Basics Class Registration Form

Contact Information

Name

*

First Name

Last Name

Pronouns

Please let us know what pronouns we should use to refer to you. You are welcome to leave this blank if you would prefer.

If you selected 'None of these', you can share your pronouns here:

Email

*

Verify Email

*

Phone

*

What is the age of the child or adolescent who is experiencing mental health symptoms?

*

This class is for parents and caregivers of youth ages 0-21.

Do you have a family member who would like to take the class with you?

Please note: They will need to register separately.

Family member name

First Name

Last Name

Family member email

Verify Email

Family member phone number

What are the main things you hope to learn from this class?

If DHS recommended you take this class in order to report results to your case manager, we'll need a signed information release form.

Are there any accommodation requests you would like us to be aware of? If so, how can we best support you with them?

Do you want your participant materials mailed to you or emailed to you?

*

Mailed

Emailed

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

How did you hear about this program?

Please tell us where you heard about NAMI Basics:

Would you like to receive emails about other upcoming programs?

This is the best way to stay up-to-date.

Anything else for us to know?