Clone of DRAFT Training Registration Form

01.16.26 Question, Persuade, Refer (QPR) Open to Community

10am - 11:30am @ The Garage - 402 St. Joseph St. Rapid City, SD 57701
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Name of the institution or company to which you are affiliated:*
Position: *
Have you served in the military or are a family member of a veteran or active member of the military?*

YesNo
Are you willing to voluntarily participate in a 3-month follow-up survey from Mountain Plains Evaluation after attending this training?*

YesNo

Demographic Information

To ensure that we can continue to serve our community, we kindly request your demographic information. Rest assured, all information provided will be kept confidential and used solely for the purpose of funding. This information is not required. Thank you for your cooperation.
Pronoun:
Age:
Ethnicity:
Race:
If other, please explain in the textbox below.

Do you need CEUs for this training?

YesNo
Do you work in mental health and/or related workforce?
If 'other', please specify:
How did you hear about this training?
If you chose 'other', please explain:
By signing below, I hereby grant the Helpline Center and it's representatives permission to use photographs and/or videos taken of me during this training for promotional, marketing and educational purposes in print, online and social media. I understand that these images may be used without further notification or compensation.
Signature

Clear
Type a question

By checking, here I wish to not be photographed in any way.Note that seating might be assigned to avoid the camera's direction.
Should be Empty:

01.16.26 Question, Persuade, Refer (QPR) Open to Community