Type/Category(Required)SelectRequestTrainingRegisterRequest(Required)SelectIn Our Own Voice Presentation RequestEnding the Silence Presentation RequestFaithNet Presentation RequestProvider Course RequestWhich Ending the Silence presentation are you requesting?(Required)Ending the Silence for StudentsEnding the Silence for School StaffEnding the Silence for FamiliesTraining(Required)SelectIn Our Own Voice Presenter TrainingEnding the Silence Presenter TrainingProvider Course Presenter TrainingFamily Support Group Facilitator TrainingConnection Recovery Support Group Facilitator TrainingFamily-to-Family Teacher TrainingMental Illness & Recovery Teacher TrainingRegister(Required)SelectNAMI Homefront CourseBecome a VolunteerBecome a MemberName(Required) First Last Pronouns(Required)What is your role at the school where the presentation is being requested?(Required)Organization name and type(Required)School name(Required)Name and type of place of worship(Required)Email address(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone number(Required)Audience size(Required)What is the approximate age range of the students?(Required)Requested presentation date(Required) MM slash DD slash YYYY Alternative presentation date(Required) MM slash DD slash YYYY Would you like an in-person or virtual presentation?(Required)In-personVirtualDo you have a diagnosed mental health condition? If so, what is it?(Required)Are you willing to present your personal story of living with a mental health condition to others?(Required) Yes No Are you willing to provide us with a professional or personal contact reference if needed?(Required) Yes No Please provide contact reference name and phone number.(Required)We will notify you if we need to contact your reference.Are you willing to present your personal story of living with a mental health condition to middle- and high-school students, their family members, and school staff?(Required) Yes No I would like to be trained as: Lead Presenter: ETS for Students Lead Presenter: ETS for Staff Lead Presenter: ETS for Families Young Presenter (age 18–35) How old are you?(Required)Do you have reliable transportation for traveling to/from presentations?(Required) Yes No NAMI Vermont provides mileage reimbursement at the IRS rate.Select your role for the Provider Course:(Required)SelectPeerFamily memberClinician/mental health professionalWhich class would you like to take?(Required)SelectWaitlist for Fall 2023 classesAre you a family member or close friend of an individual with a mental health condition?(Required) Yes No Not sure/Don’t know What is your loved one's mental health diagnosis?(Required)What is your relationship to this person?(Required)Does this person live with you? If not, how far away do they live?(Required)Have you attended a Family Support Group meeting before?(Required) Yes No Have you attended a Connection Recovery Support Group meeting before?(Required) Yes No Have you completed a Family-to-Family class before?(Required) Yes No Are you a veteran/service member?(Required) Yes No Are you a loved one of a veteran/service member?(Required) Yes No Which course would you like to take?(Required)SelectSchedule date(s) and location(s)Waitlist for future classesWhat do you hope to gain from this class?(Required)What do you hope to gain from this course?(Required)How would you like to be involved with NAMI Vermont?(Required)Membership type:(Required)SelectIndividual ($40 for yearly membership)Household ($60 for yearly membership)Open Door ($5 for yearly membership for those with limited financial resources)Names of household members:(Required)Tell us about yourself and your mental health journey. (optional)How old are you? (optional)This field is hidden when viewing the formWill you need any special accommodations? If so, please state them.This field is hidden when viewing the formIs there anything else you’d like us to know?Will you need any special accommodations? If so, please state them.Is there anything else you'd like us to know?How did you find out about NAMI Vermont?I would like to receive the NAMI Vermont e-newsletter. Yes PhoneThis field is for validation purposes and should be left unchanged.
