Mental Health First Aid – Thrive Community Health Network

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First Name*

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Last Name*

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Phone*

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Email*

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Date of Birth*

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County of Residence*

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How did you hear about this class?*

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May we contact you for future events or trainings?YesNo

Thrive Community Health Network’s programs are funded through grants from different agencies and foundations. To continue to receive funding and offer services in our community, we have to report on the demographics of the people served in our programs. Please help us learn more about our program participants by answering the following questions. You may select “choose not to answer” if you do not wish to provide the information. Thank you!

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What gender do you identify with?*

What race do you identify yourself as?

Please specify your ethnicity.

What language are you most comfortable speaking?

Do you speak Spanish fluently?

What is your veteran status?

What type of health insurance do you have?

What is your current employment status?

What is the highest grade or year of school you have completed?

How would you rate your personal/family’s financial situation?

What is the total income for your household per year?

How many people, including yourself, do you live with?

What town/city do you live in?

Please select class:*

How many youth?

Would they benefit from childcare?

Dietary Restrictions

Do you have any dietary restrictions?

During this class we may take photos. Please indicate your willingness to have your photo taken.I am willingI am not willing