RCCMHC 101 Training Survey

Date of training

Date

Please list up to two parents / caregivers living in your household that attended tonights training.

NOTE: If the other adult you registered does not live with you, they will need to fill out a separate form.

Caregiver 1

First NameLast Name

I prefer to receive my gift card by: (Caregiver 1)

Phone Number (caregiver 1)

Area CodePhone Number

Email (caregiver 1)

example@example.com

Caregiver 2

First NameLast Name

I prefer to receive my gift card by: (Caregiver 2)

Email (caregiver 2)

example@example.com

Phone Number (caregiver 2)

Area CodePhone Number

i live in ramsey county

my children attend the following school district(s): (check any that apply)

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