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5. Mailing Street Address

6. Mailing Address - City

7. Mailing Address - State

8. Mailing Address - Zip Code

9. Cell Phone

10. Time Zone

11. Check the group(s) that you currently belong to: 1.) ALLIANCE MEMBER - is specifically for those individuals NOT in Michigan - that are part of the Alliance for the Advancement of Infant Mental Health 2.) DWIHN - If you work at one of the IECMH organizations within "Detroit Wayne Integrated Health Network", check BOTH DWIHN AND either Non-Member or MI-AIMH Member 3.) MI-AIMH MEMBER - Select if you are a current MI-AIMH Member 4.) NON-MEMBER - Check if you are NOT a MI-AIMH Member 5.)STUDENT - Current students will be required to email a copy of their current student ID or class schedule to lsheldon@mi-aimh.org

Alliance Member Detroit Wayne Integrated Health Network (DWIHN) MI-AIMH Member Non-Member Student

12. Enter either your MI-AIMH Member ID or your Alliance State/Country if you checked YES to MI-AIMH Member or Alliance Member on the previous question

13. Agency/Organization

14. Please indicate your discipline

BA BS BSN BSW EdD LLP LP LPC MA MEd MS MSN MSW PhD PsyD Other

15. Please indicate your primary practice setting.

Child Welfare Community Mental Health Early Care (Child Care) Early Headstart Early On/Early Intervention Headstart Homevisiting Other Home Visiting (Parents as Teachers; Healthy Families America, etc.) Hospital Setting Maternal Infant Health Program (MIHP) Not Currently Practicing Private Practice Students Tribal Health University Faculty Administration

16. How many years have you been working on behalf of infants, young children and families?

Under a year 1-5 years 6-10 years 11-15 years 16-20 years 21+ years

17. Check the continuing education credit type(s) you will need for your professional development.

Social Work Professional Counselor State Continuing Education Clock Hours (SCECH): as a certified teacher/school administrator (elementary and secondary) Not applicable at this time

18.

19. Are you a professional who needs their attendance verified on: https://www.miregistry.org/ such as Early Childhood Educators, Center Based Directors etc. for your work? If so, please add your MiRegistry Number below so we can add your attendance to your training log. MiRegistry.org is not hosted by or affiliated with MI-AIMH, and you do NOT need to have a MiRegistry profile in order to participate in the MI-AIMH Conference. This is optional and only for those required to have their trainings in miregistry.org for their work.