NCHS Member Application Request
Please answer the questions below to request more information about NAMI on Campus High School Clubs.  The information collected in this form is completely confidential and will only be shared with your NAMI on Campus High School Club Advisor(s).  Please contact Kym Barber, by email at: kbarber@stancoe.org or text/call (209) 224-4760 for more information.
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Email *
Name *
First and Last Name (include your preferred name)
What School do you attend? *
Grade Level 2023-2024? *
Home Mailing Address (Please include Street Number, Street Name, City and Zip Code)  we're collecting this if we need to mail you NAMI on Campus merch!
Student Cell Phone Number *
Additional Phone Number (if no answer, we'll call this one if there's an emergency)
Age? *
What is your Ethnicity? *
Required
Gender. How do you identify? *
What is your primary language?  *
T-Shirt Size (just in case)
Clear selection
We're so glad you're interested in joining NAMI on Campus.  What got you interested?  (check all that apply)
My favorite way(s) to learn something new is:  (check all that apply)
Topics that I'd like to learn more about are: (check all that apply to you)
What is your current knowledge level for the following topics:
No Knowledge
Some Knowledge
Very Knowledgeable
Suicide Prevention Hotline
Mental Health Resources
Mental Illness
Symptoms of Mental Illness
Stigma of Mental Illness
Self-Care and Wellness
Youth Advocacy for Mental Health Issues
Peer-Support
Bullying Prevention
Clear selection
Skills I'd like to develop while a member of the NCHS Club are: (select all that apply to you)
Are you ready to join NAMI on Campus Club? (check all that apply)  *
Required
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