Cohort Three
This form is designed for those who are currently interested in registering for the AS+K? About Suicide to Save a Life Training of Workshop Leaders. We ask that you fill in the information below to the best of your ability. Thank you
First Name: *
Last Name: *
Email Address: *
Title: *
Organization: *
Street Address: *
City: *
State: *
Zip Code: *
Phone Number: *
Supervisor's Phone Number/Email (in case of emergency during training): *
Mailing address for materials (if different from address listed above):
In what county in SC do you reside? *
Are you willing to provide the training a minimum of five times throughout the year? *
Where do you plan to provide the training? (Please include county, name of organization or group, and the populations you plan to train) *
Are you a SC Department of Mental Health employee? *
If you are a SC-DMH employee, please list your DMH email below:
Previous suicide intervention trainings attended: *
Does the following statement apply to you: In the last three years, I have been directly impacted by suicide through a family member, friend, coworker, or client. *
Does the following statement apply to you: I have not been personally impacted by suicide in the above ways but I care about this issue and want to help. *
Please list any other community members and their contact information who may be interested in being a part of this training.
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