LEAP Registration

Name*

First Last

Address

Street Address Address Line 2 City State

Zip Code*

Daytime Phone*

Cell Phone

Email

Ethnicity*

Age*

You are a:*

Please check all that apply

Are you a NAMI member?

How did you hear about L.E.A.P.?*

Which one?

Please specify how you heard about this class

Relationship to family member living with mental illness?*

Example: brother, wife, partner

Please provide their age*

Are other members of your family taking this class?

What is their name?