Application: Mental Health First Aid Instructor Certification Training Part I: Applicant Information Name: (first, last) Applicant Type: am applying as an independent trainer ☐I am applying as an agent of my employer ☐I please specify: ☐Other, Organization Name: (if applying as an of your employer) Organization Type: ☐Private ☐Public ☐Not-for-profit ☐For-profit please specify: ☐Other, Industry Type: community ☐Faith ☐Corporate resources/Employee Assistance Program ☐Human enforcement/public safety ☐Law education ☐Higher education ☐Primary/secondary ☐Hospitality adults services ☐Social healthcare ☐Behavioral healthcare ☐Other ☐Government please specify: ☐Other, Organizational Service Area: ☐Urban ☐Suburban ☐Rural ☐Frontier Email: Primary Number: Secondary Phone Number: Mailing Address: Desired Training Date and 1st Choice Location: Date: (For a full list of trainings offered, .) Location: 2nd Choice Date: Location: Are you applying for a youth or ☐Youth adult instructor training? ☐Adult Full or expedited training? Day training for new instructor ☐5 Day training for current instructor ☐2.5 Does your organization have a ☐No primary contact for Mental Health ☐Yes First Aid activities?
Application: Mental Health First Aid Instructor Certification Training Part I: Applicant Information Name: (first, last) Applicant Type: ☐I am applying as an independent trainer ☐I am applying as an agent of my employer ☐Other, please specify: Organization Name: (if applying as an of your employer) Organization Type: ☐Private ☐Public ☐Not-for-profit ☐For-profit ☐Other, please specify: Industry Type: ☐Faith community ☐Corporate ☐Human resources/Employee Assistance Program ☐Law enforcement/public safety ☐Higher education ☐Primary/secondary education ☐Hospitality adults ☐Social services ☐Behavioral healthcare ☐Other healthcare ☐Government ☐Other, please specify: Organizational Service Area: ☐Urban ☐Suburban ☐Rural ☐Frontier Email: Primary Number: Secondary Phone Number: Mailing Address: Desired Training Date and Location: (For a full list of trainings offered, .) 1st Choice Date: Location: 2nd Choice Date: Location: Are you applying for a youth or adult instructor training? ☐Youth ☐Adult Full or expedited training? ☐5 Day training for new instructor ☐2.5 Day training for current instructor Does your organization have a primary contact for Mental Health First Aid activities? ☐No ☐Yes
MHFAInstructorCertificationApp3.docx