ASIST Training Registration Form

Complete this form to register for ASIST training. When you have submitted your registration information, the next page will give you the opportunity to pay the $299 registration fee securely using PayPal. If you prefer, you may print out and mail your application along with your check.

* indicates required field

Select a training session:

Saturday-Sunday, October 3-4

Last Name *

First Name *

Age

Street Address *

City *

State *

Zipcode *

Home phone *

Work phone

Mobile phone

E-mail address *

Education (highest level)

High School
Voc/Trade School	Specialty
Some College	Major
College Degree	Major
Graduate Degree	Major
Other training

Occupation

Current Employer (name and address)

Start Date

Title

Previous Mental Health or Suicide Intervention Training (specify):

Previous Active Listening Training (specify):

Life Experiences, Volunteer Work, Special Skills, etc.:

Experience with Suicide, either third party or self that might interfere with your performance in the course:

What prompted you to take interest in this course (specify):

How did you learn of CONTACT?

Newspaper	Name
Internet Site	Website
Brochure/Newsletter
Friend/Word of Mouth	Name
Other	Specify

Website by Foxglove Systems

Accounting/Financial	Government	Mental Health/Social Services
Administrative/Clerical	Health/Medicine	Professional
Clergy	Homemaker	Education
Management/Executive	Skilled Craft/Trade	Engineering/Technical
Marketing/Sales	Other
Retired (from)