Registration: Empowering Response

Name*

First Last

Credentials*

Agency/Organization*

Job Title/Current Position*

Mailing Address*

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

Mobile Phone Number*

(PS ROTA-R Staff will be sending weekly SMS text messages related to series content. By inputting your phone number, you consent to receive text messages sent from an automated texting system.)

Email*

Enter Email Confirm Email

(by providing your email address, you will automatically be added to the PS ROTA-R mailing list; to opt-out, please contact psrotar@casat.org)

Password*

Enter Password Confirm Password

Strength indicator

What do you hope to learn by taking the Empowering Response EPL Series?

How did you learn about this event?

What county/counties do you serve?*

Gender

Male
Female
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
Asian
Black or African-American
Native Hawaiian
Pacific Islander
White
Other

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.