Community Counseling Centers of Chicago (C4) Mental Health First Aid 12-hour Training Registration Form Name: Organization:

Address: Telephone: E-mail: ________________________________________ ________________________________________ ________________________________________ ________________________________________ home home home business business business other other other

________________________________________ (required)***

Please indicate the dates of the training you plan to attend: ______________from 9am to 4pm. MHFA trainings are being offered FREE of cost to Chicago area participants thanks to funding provided by the State of Illinois Department of Human Services/Division of Mental Health. Professional development credits are available at a fee of $15.00 per 12 credits. Each participant receives certification, MHFA Manual and Resource Guide, and a light lunch.
Professional Development: I am interested in obtaining: 12 Continuing Professional Development Units (CPDUs)* for educators 12 Continuing Education Units (CEUs)** for LCPC and LCSWs 12 Continuing Education Units (CEUs) *** for substance abuse professionals 12 Contact Hours**** for nurses 12 General Recertification Credit Hours***** for human resources professionals Fees total: $15.00 $15.00 $15.00 $15.00 $15.00

Payment Information (for professional development credits only):

Please note -- any forms received requesting professional development units without payment information will not be processed. Check or Money Order: Mail payment & registration form to: C4 Attn: MHFA, Jessica Wheeler 4740 N. Clark Street Chicago, IL 60640 Credit Card: Type: _________________________________ Credit Card Number: __________________________________ Name as it appears on card: _____________________________ Exp. Date _____________________ Amount $ _____________________

I hereby agree to attend both dates (all 12 hours) of the above specified Mental Health First Aid training. I understand that failure to attend all 12 hours of training will result in forfeiture of certification. Name:_____________________________________________
Community Counseling Centers of Chicago

Date:________________
Revised on 7/6/2011

Please forward completed form(s) to Jessica Wheeler at Jessica.Wheeler@c4chicago.org or fax to (773)765-0828. Confirmation of registration will be sent via e-mail upon receipt of completed registration form within one week of training date. In the event that the selected training registration has closed or is at capacity, notification will be sent of alternate training dates and/or placement of your name on our waiting list. ###
* This continuing education activity was approved by the Illinois State Board of Education. ** This continuing education activity was approved by the Illinois Department of Financial and Professional Regulation. *** This continuing education activity was approved by the Illinois Alcohol and Other Drug Abuse Professional Certification Association, Inc. for the following categories: Counselor I or II, Prevention I, Assessor I or II, MISA I or II or III, CCJP II, PCGC II, CAAP I, CRSS I or II, BRI II, MAATP I or II, RDDP. **** This continuing nursing education activity was approved by the Illinois Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. ***** This continuing education activity was approved by the Society for Human Resource Managements HR Certification Institute.

Community Counseling Centers of Chicago

Revised on 7/6/2011