Registration Form- Many Pathways to Recovery-Rising Up Together
Region V Consumer/Family Behavioral Health Conference
Registration Application
June 2nd, 2022
8:00 am – 4:00 pm
The Consumer/Family Advisory Committee is pleased to offer scholarships to the 2022 “Many Pathways to Recovery” Consumer and Family Behavioral Health Conference.  These registrations are given to those who experience mental illness, substance use, and/or co-occurring disorders, family members, veterans and peer support specialists residing in the Region V area.

*****Please complete the registration form on or before the deadline of: May 6th, 2022*****

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Name *
Organization
Title
Address
County, City, State, Zip *
Phone
Email
I identify as a : (Check all that apply) *
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I will be attending: (select all meals that apply)
1. Why do you wish to attend the conference?
2. How will you, your family and/or organization benefit from your attendance?
3. What are the specific issues relating to behavior health in which you are most interested?
4. Are you currently involved with any behavioral health programs and/or activities in your community that will be enhanced by your attendance at the conference?  If yes, please describe.
• To be eligible for this registration, you must reside in the Region V area and be a consumer of behavioral health services.  You will be asked to submit a conference evaluation at the end of the conference before receiving a Certification of Attendance.                • NOTE:  Names and contact information of individuals receiving scholarships may be made available to your Region V Administration. *
Digital Signature: By typing your name in the box below, you are signing this registration form. *
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