Westside Los Angeles
NAMI Basics Registration Form
Please fill out the form below.
Your information will be kept confidential.
Name:
Address:
City & State:
ZIP Code:
Phone:
Ext.
Email:
Please register
Select
1
2
attendee(s) for the classes.
How did you hear about this class?
Select
Flyer
Newsletter
Physician or Psychiatrist
Social Worker
Friend
Relative
Other (Specify Below)
Other:
What is your relationship to your affected child or adolescent?
Select
Parent
Sibling
Caregiver
Other (Specify >)
Other Relationship:
How old is your affected child or adolescent?
Type comments or questions here.
NAMILA.org