Digital Peer Support – Registration 8.5.1

Name*

First Last

Credentials*

Email*

(By providing your email address, you will automatically be added to the Mountain Plains ATTC listserv; to opt-out, please contact MPATTC Staff at mpattc@casat.org)

Enter Email Confirm Email

Password*

Enter Password Confirm Password

Strength indicator

Agency/Organization*

Current Position*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

State where you work:*

Daytime Phone Number*

(Mountain Plains ATTC 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 texting system.)

How did you learn about this event?*

What do you hope to learn by participating in this online learning series?*

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

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