Registration – COD 3.5.1

Name*

First Last

Credentials*

Agency/Organization*

Job Title/Position*

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Phone Number

Cell Phone Number*

(NFARtec Staff will be sending weekly SMS text messages related to course content. By inputting your phone number, you consent to receive text messages sent through an automatic telephone dialing system.)

Email*

Enter Email Confirm Email

Password*

Enter Password Confirm Password

Strength indicator

How did you find out about this event?*

What is one specific question about co-occurring disorders you would like answered?*

What is your gender?*

Female
Male
Transgender
Other

Do you identify as LGBTQ+ (Lesbian, Gay, Bisexual, Transgender, or Queer)?*

Yes
No

Are you Hispanic or Latino/a?*

Yes
No

What is your race? (select one or more):*

Alaska Native
American Indian
Native Hawaiian
Other Pacific Islander
Asian
Black or African American
White
Other (please specify)

(Please specify)

By checking here you are indicating that you understand the pre-requisite and technology requirements as well as the time commitment to participate in this training.*

I understand the time commitment involved and agree to fully participate.