Substance Misuse Training Registration

Substance Misuse Training Registration

Training Dates/Times

Dangers of Vaping

Wednesday, January 29th from 10:00am-11:00am

RX360

Tuesday, January 21st from 1:00pm-2:00pm

Tuesday, Feb 4th from 10:00am-11:00am
Wednesday, Feb 19th from 1:00pm-2:00pm

Marijuana 360

Wednesday, Feb 12th from 11:00am-12:00pm
Thursday, Feb 27th from 2:00pm-3:00pm

Your Registration Choices

Date of training you are registering for

Time (ex. 11:00 AM)

Thank you in advance for completing the questions below to satisfy the reporting requirements for our funder.

Participant Information

First Name

Last Name

Work Email - for Certificate & Zoom Link

What Organization are you from

CCHCI provider or staff memberCODAC provider or staff memberGeneral PublicHealthy Families-CFR Other employee of CFR-please enter belowOther Organization- please enter below

Other Organization

Other Child & Family Resources Staff

Which CFR HF Team are you a part of?

Other Program

What Zip code do you live in? (5 digits only)

What County do you live in

Apache County	Cochise County
Santa Cruz County	Coconino County
Gila County	Graham County
Greenlee County	La Paz County
Maricopa County	Mohave County
Navajo County	Pima County
Pinal County	Yavapai County
Yuma County

What is your age?

Do you have a disability that you need accommodations for?

YesNoPrefer not to respond

What is your gender identity

MaleFemaleTrans ManTrans WomanGender non-conformingOtherGender UnknownPrefer not to respond

Preferred Language

EnglishSpanishOther preferred language-please provide

Other preferred language

How would you describe your Ethnicity

Hispanic/LatinxNon-Hispanic/LatinxPrefer not to respond

How would you describe your Race (hold CTRL to select multiple)

Household Income Information

Below Federal Poverty level (see chart)

YesNoPrefer not to respond

Federal Poverty Guidelines

Additional Information

Please list any other CFR programs that you are involved in

How did you hear about this program

Free Material Available

Would you like a FREE medication lock bag? If yes, provide email contact information above.

YesNo

Would you like a FREE box of Narcan Nasal Spray? If yes, provide email contact information above (Narcan offered with RX 360, Trauma-Informed RX 360 Substance Misuse & Naloxone trainings and Rise of Fentanyl & Naloxone only).

YesNo

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Contact Information