NAMI Basics Registration

Your name:*

First Last

The session I would like to register for is:*

The Child(ren)/Adolescent(s) I am taking this course to support is named:*

First

First name only please

The Child(ren)/Adolescent(s) I am taking this course to support is my:

Son, Daughter, Niece, Nephew, Foster Child, Grandchild, Other

My Email

My phone number:

Cell Phone Carrier

The physical address where you will take the class*

Street Address Address Line 2 City State ZIP Code

Primary Diagnosis of loved one:

Hold down the control key to mark multiple selections

This individual lives with:*

Childs age*

Please enter a number from 0 to 20.

Child is in:*

Class materials can be made available:*

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