San Bernardino County Recovery Happens 2022

Attendee Registration form

First Name

Last Name

What is your age?

What sex were you assigned at birth?

How do you describe yourself?

What is the primary language spoken in your home?

Are you a consumer of mental health services?

Are you a friend, family member, or loved one of a consumer of mental health services and/or alcohol and drug services?

Have you ever served in the military?

Which category best describes your race (i.e. physical/ancestral characteristics)?

Which category best describes your ethnic/cultural background?

Do you consider yourself:

Do you work in any of the following areas/fields? (check all that apply)

Which best describes your employer:

Do you live or work in San Bernardino County, if both list the region you live in:

Please specify which region in San Bernardino County:

Zip Code:

Do you have a disability or other impairment that is expected to last longer than 6 months and substantially limits major life activity, which is not the result of a severe mental illness?