Mental Health First Aid for Public Safety
Complete & electronically sign form

For more information on the Center for Policing Excellence, please visit our website at: http://www.oregon.gov/DPSST/CPE/pages/index.aspx

Date of Training: Monday, July 17, 2017
Location of Training: Chemeketa Community College
4910 Brooklake Rd NE
Brooks, OR 97305
Student Name
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DPSST # (required for certified personnel)
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Rank/Title
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Discipline
Employing Agency
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Agency Mailing Address
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Work Email (notice of confirmation will be sent to this address)
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Secondary Notification Email
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Office Phone (w/extension)
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Work Cell Phone
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Supervisor's signature authorizing participation IS REQUIRED
By (electronically) signing below, I affirm that the applicant(s) listed on this registration application and any attached sheet(s) is/are approved by me to attend the training listed above.
Supervisor's Electronic Signature (print full name)
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Supervisor's Rank/Title
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Date
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