Name

Your organization or Group Name (If this is a personal request, please write “Individual”)

Phone

Email Address

Message

County where training would take place County where training would take place Leavenworth Atchison Jefferson Virtual Other

Type of Request (Please check all that apply) Type of Request (Please check all that apply) QPR (Question, Persuade, Refer) Gatekeeper Training Suicide Prevention Presentation Lethal Means Safety Training (e.g., gun locks, medication safety) Youth-focused Suicide Prevention Military/Veteran-focused Suicide Prevention Tabling at an Event Other (please describe)

Who is the audience? (Example: high school students, staff meeting, faith leaders, parents, first responders, etc.)

Estimated Group Size Estimated Group Size Fewer than 10 10-25 25-50 50+

Preferred Date(s) or Timeframe (If unsure, write “Flexible” or describe your ideal timeframe)

Location

Anything else we should know?