Outreach Program Sign Up Form

First Name *

Last Name *

Organization

Email Address *

Phone Number *

For descriptions of each of the trainings below, please visit our website at https://diversushealth.org/outreach-program/

Please reach out to CommunityOutreach@diversushealth.org for non-profit pricing

Are you signing up as an individual or organization? *

Individual

Organization

Question Persuade Refer - 8:00am-10:00am -

January 17, 2025 (26 remaining)

February 14, 2025 (27 remaining)

March 14, 2025 (30 remaining)

April 11, 2025

ASIST - $175 per participant

February 11 & 12, 2025 - $175 (30 remaining)

May 6 & 7, 2025 - $175 (30 remaining)

August 5 & 6, 2025 - $175 (30 remaining)

November 4 & 5, 2025 - $175 (30 remaining)

Lunch will be provided. Please list any dietary restrictions below: *

Mental Health First Aid - Adults (MHFA) 8:30-5

January 28, 2025 (18 remaining)

February 25, 2025 (24 remaining)

March 25, 2025 (28 remaining)

April 29, 2025 (28 remaining)

Would you like a boxed lunch? (this will be an additional $17 to cover delivery fees, etc.)

Yes

No, I plan to bring my lunch

Please choose your meal (meals are from Panera, sandwiches come with chips and a cookie, and salads come with a baguette and a cookie) *

Youth Mental Health First Aid (YMHFA)- 9am - 4pm

April 17, 2025 (25 remaining)

June 26, 2025 (30 remaining)

October 2, 2025 (30 remaining)

Would you like a boxed lunch? (this will be an additional $17 to cover delivery fees, etc.)

Yes

No, I plan to bring my lunch

Please choose your meal (meals are from Panera, sandwiches come with chips and a cookie, and salads come with a baguette and a cookie) *

Classes cover up to 30 students. Meals are not included.

Please select a training (reach out to communityoutreach@diversushealth.org if you are unsure which training to do):

ASIST ($6,000)

MHFA ($3,000)

YMHFA ($3,000)

Enter non profit discount code:

Please list your preferred dates. We will reach out to confirm dates. *

Current Total:

$0.00

*

By checking this I agree that this transaction is non-refundable and can allow up to one transfer of dates.