Training Registration Name(Required) First Last Phone(Required)Email(Required) Agency/Organization (if applicable) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County(Required)AllenAndersonAtchisonBarberBartonBourbonBrownButlerChaseChautauquaCherokeeCheyenneClarkClayCloudCoffeyComancheCowleyCrawfordDecaturDickinsonDoniphanDouglasEdwardsElkEllisEllsworthFinneyFordFranklinGearyGoveGrahamGrantGrayGreeleyGreenwoodHamiltonHarperHarveyHaskellHodgemanJacksonJeffersonJewellJohnsonKearnyKingmanKiowaLabetteLaneLeavenworthLincolnLinnLoganLyonMarionMarshallMcPhersonMeadeMiamiMitchellMontgomeryMorrisMortonNemahaNeoshoNessNortonOsageOsborneOttawaPawneePhillipsPottawatomiePrattRawlinsRenoRepublicRiceRileyRooksRushRussellSalineScottSedgwickSewardShawneeSheridanShermanSmithStaffordStantonStevensSumnerThomasTregoWabaunseeWallaceWashingtonWichitaWilsonWoodsonWyandotteWhich training are you registering for?(Required) Youth Mental Health First Aid (YMHFA) Question, Persuade, Refer (QPR) Applied Suicide Intervention Skills Training (ASIST) Youth Mental Health First Aid(Required) May 1st – 9:00 AM-5:00 PM - Topeka - DCCCA Building June 20th - 9:00 AM-5:00 PM - Garden City Question, Persuade, Refer (QPR)(Required) April 25th – 12:00-2:00 PM - Topeka - DCCCA Building May 6th - 11:00 AM-1:00 PM - Girard - Greenbush May 30th - 12:00-2:00 PM - Hays - Fort Hays State University June 2nd - 9:00-11:00 AM - Dodge City - Depot Theater June 5th - 11:00 AM-1:00 PM - Wichita - DCCCA Gym Applied Suicide Intervention Skills Training (ASIST)(Required) June 2nd – Wichita - DCCCA Building June 5th - Garden City - St. Catherine Hospital June 16th - Parsons - Labette Center June 19th - Hays - USD 489 District Building How did you hear about this training?(Required)Do you require any accommodations to participate in this training?(Required) Questions, comments, concerns?
