Registration: PS ROTA-R Healthy Living, Sustainable Recovery EPL

Name*

First Last

Credentials*

Agency/Organization*

Current Position*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

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)

Enter Email Confirm Email

Password*

Enter Password Confirm Password

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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 through an automated texting system.)

What do you hope to learn by taking the Healthy Living, Sustainable Recovery EPL Series?*

How did you learn about this event:*

What county/counties do you serve?*

Your gender:

Male
Femal
Transgender

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

Yes
No

Are you Hispanic or Latino/a/x?

Yes
No

What is your race? (select one or more)

Alaska Native
American Indian
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.