Washington Association for Infant Mental Health

Are you completing this registration form for yourself or someone else (e.g., a staff member)?

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Myself

Someone else

Contact Information

Name

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First Name

Last Name

Email

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Verify Email

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Organization/Employer

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Program model, if applicable (e.g., Parents as Teachers, Nurse-Family Partnership)

County of residence

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CEUs/STARS/clock hours

Would you like to receive CEUs?

CEUs will be available for mental health professionals. The CEU fee is $45 for 21 hours.

Yes

No

Would you like to receive STARS hours?

Yes

No

Please enter your STARS ID.

Payment

You must click "submit" at the bottom of the page to complete your registration and proceed to payment.

Registration Amount

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$350 - Registration fees (no CEUs)

$395 - Registration fees (with CEUs)

Training Demographics Survey

Optional: The data collected below allows us to better understand our training participants and can help us communicate our impact to scholarship funders. Data is only reported for groups as a whole--your individual information will be kept confidential. By filling out the survey below, you are acknowledging that the information you provide can be included in WA-AIMH summaries and reports. Please provide any information that you are comfortable sharing. WHEN YOU ARE FINISHED, PLEASE CLICK 'SUBMIT' AT THE BOTTOM TO COMPLETE YOUR REGISTRATION.

Profession

Highest degree earned

High School/GED

CDA

Associates

Bachelors

Masters

Doctorate

Medical or Law

Field Employed

Please describe.

Field Employed (other)

Years worked with infants, young children, and families

Less than 2 years

2 - 5 years

5 - 10 years

10+ years

Individual annual income

<$10,000

$10,000-$30,000

$30,000-$50,000

$50,000-$70,000

$70,000-$90,000

$90,000+

Do you directly support families on a weekly basis?

Yes

No

Ethnic background

Do you supervise staff who directly support families?

Yes

No

Ethnic background (self-describe)

Please describe.

Gender

Preferred language

Please describe your gender (if desired).

Age range

Please click "submit" to complete your registration below.

We will contact you to confirm your registration.

The Growing Brain

Contact Information

CEUs/STARS/clock hours

Payment

Training Demographics Survey