Registration Form - NAMI Dubuque

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General Registration Form

Today's Date *

YYYY

Full Name *
*

Mailing Address *

Residential Zip Code *

Phone Number * *

Date of Birth *

YYYY

Email * *

If you do not have access to an email address, please use: N/A

Do you have insurance? *

Yes

Which county are you obtaining todays services? *

Dubuque

Delaware

Jones

Are you here during our peer-run wellness hours? *

Yes

Other:

Program Registration *

Class: Family-to-Family (Date: 1/13-3/3 2025, Location: NAMI Dubuque)

Class: Peer-to-Peer (Date: 1/23-3/13, Location: NAMI Dubuque)

Peer Programs / 1:1 Support Services

Family Programs

Other:

Age Group *

16 - 18

18 - 25

26- 35

36 - 45

45 - 55

55 - 65

65 +

Other:

Income level (annual, est.) *

Under $25,000

$25-$35,999

$36-55,999

$56-75,999

$76-100,000

Prefer not to say.

Other

Demographic/Nationally (use N/A if you prefer not to answer) *

White, Non

Gender Identity (use N/A if you prefer not to answer) *

NAMI Dubuque Member? (optional) *

YES

I would like to join

How did you hear about NAMI? *

Would you like to receive our newsletters?

Please note, we do not do direct mailing.

YES!

I already do.

No thank you.

Communication: We use email, often. We communicate schedules changes, program cancellations and updates for our classes. A class leader may need to reach you in the event of an update, by selecting yes, you acknowledge that you are aware of our communication policy. Alert your program leader for other preferences. *

Yes

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