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

Have you read "I Am Not Sick I Don't Need Help!"?*

What is your relationship to the person living with mental illness?*

Example: my brother, my partner, my step daughter, my friend, my wife

Please provide their age*

Are other members of your family taking this class?

What is their name?