Preferred Course Dates:

Personal Details

Preferred title (circle) Miss / Ms / Mrs / Mr

First Name

Preferred Name

Last Name

Contact Details

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Email

Postal Address

Current Employment

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Intentions

What would you most like to learn and get out of doing a Mental Health First Aid Course?

Do you have any dietary requirements? (e.g. gluten-free or dairy-free etc.)

How did you hear about this course? Email □ Social media □ Colleague or friend □ Other:

Please email this completed form to: mhfa@stepstone.org.nz

If you would like more information, phone Stepping Stone Trust on: 03 338 6390

or view our website: www.stepstone.org.nz/education/mhfirstaid/