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QPR Registrations
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2024-02-19T23:42:47+00:00
Registration for Question, Persuade, Refer (QPR) Suicide Prevention Training
Name
First
Last
Email Address
(Required)
Which class would you like to attend?
(Required)
Thursday, November 14 | 2:30pm - 4pm
Tuesday, November 26 | 11am - 12:30pm
Thursday, December 19 | 9am-10:30pm
Tuesday, January 7 | 1pm – 2:30pm
Are you in the health or first responder workforce?
(Required)
Examples: Nurse, Social Worker, Peer Health Navigator, Counselor, School or Family Supports, Healer/Elder, Outreach Worker, Law Enforcement, EMS, etc.
Yes
No
Don't know
Prefer not to say
Address
(Required)
Every person who is trained in QPR is given a pocket reference guide. Please fill out your mailing information so we can send your copy after the training.
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Additional Information
As part of our program delivery, we gather information to help us understand who is, and who is not, receiving services. The information you provide will be securely stored, will not be shared with other participants, and will be reported without your name or identifying information (aggregated). Thank you for filling out the following questions honestly and completely. Only your email, mailing address, and connection to the health workforce are required to attend the training but your complete answers allow us, and our funders, to demonstrate the importance of prevention services to our community.
How old are you?
16-18
19-25
26-35
36-45
46-60
61+
Prefer not to say
What is your gender?
Female
Male
Non-binary
Prefer not to say
Other
Are you part of the LGBTQ+ community?
Yes
No
Don't know
Prefer not to say
What is your race/ethnicity? (select one)
American Indian / Alaska Native
Asian-Chinese
Asian-Filipino
Asian-Japanese
Asian-Korean
Asian-Vietnamese
Black
Native Hawaiian/Pacific Islander
Native Hawaiian/Other Pacific Islander - Samoan
Native Hawaiian/Other Pacific Islander - Other
White
Two or more races (multi-racial)
Prefer not to say
Other
Are you Latino(a)? (select one)
Yes
No
Prefer not to say
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