AMERICAN INDIAN
MENTAL HEALTH
WORKSHOP APPLICATION


**Participants will be selected based on their likelihood of teaching or utilizing this material professionally. The program is designed primarily for instructors at universities, colleges, medical and other professional schools in Southern California who teach courses on minority mental health, as well as local, state or federal instructors responsible for cultural competency trainings.**

Contact Information
Salutation
(Dr., Mr, Ms... ) :
First Name:
Last Name:
Degree
(PhD, MS, RN...):
Organization or School:
Position or Title:
Address 1:
Address 2:
City:
State:
Email:
Zip code:
Phone Number:
Fax Number:
Best time to call:

Registration Information

Please check all that apply to you: Instructor/ Professor (Grad level)
Instructor/ Professor (Undergrad level)
Cultural Competancy Trainer
Mental Health Practitioner
Public Health Practitioner
Healthcare Provider (Physician, Nurse, etc.)
Academic Researcher
Other
Please provide additional details
regarding boxes checked above:
I teach course(s) that include content on:
(Check all that apply; If none apply leave boxes unchecked.) 		American Indian Health
Mental Health of Racial/Ethnic Minorities
Behavioral Health of Racial/Ethnic Minorities
Other
If Other please specify:
I teach or am responsible for cultural competency trainings in the area of:
(Check all that apply; If none apply leave boxes unchecked.)		 Mental Health
Health or Behavioral Health
Other
If Other please specify:
If selected to participate in the workshop, would you be willing to share your instructional materials or techniques with the Workshop Organizing Committees?
Yes No N/A
Would you be willing to share your instructional materials or techniques with the larger participant group if the Workshop Organizing Committees find it appropriate? (Your materials might be useful to other educators who participated in the workshop and want to incorporate content on American Indian mental health into their curricula.)
Yes No N/A
Would you be willing to share your instructional materials or techniques on a website where other instructors interested in teaching American Indian mental health could access it?
Yes No N/A
Would you be willing to be contacted periodically to fill out a questionairre on how the information and skills presented through this workshop have impacted your teaching?
Yes No

THANK YOU!