Registration Form

Campaign ID

Event Center

Center Event ID

Modality

Number Registered

Max Capacity

Catering?

Yes

Start Date

End Date

Start Time

End Time

If you have any questions or concerns, please email SCSMH-main@uiowa.edu, and we will work with you to make any accommodations.

If you require an accommodation to attend, please contact us at (319) 335-5623 or tlc@uiowa.edu at least 2 business days prior to the event.

First Name

Last Name

Personal Email

Work Email

Student Email

Mobile Phone Number

Content area you teach

Organization/Business: Which of the below best describes your job title?

Organization Employee

University/College/Institution Name (Start typing the name to see results)

University Student Role Salesforce ID

Role #6

Student

My University or College is not listed

My University/College/Institution is not listed

University/College/Institution Information

University/College/Institution Name

New University/College Street Address

New University/College City

New University/College State

New University/College Zip Code

New University/College Country

Which degree program are you currently pursuing?

Your anticipated graduation date (e.g., Spring 2026)

Which degree program are you currently pursuing?

Your anticipated graduation date (e.g., Spring 2026)

Additional Information

Are you a University of Iowa graduate?

YesNo

Is this your first time attending a Scanlan Center for School Mental Health professional learning event (i.e. workshop, webinar, training)?

YesNo

Are you a parent to a PreK-12 student?

YesNo

The University of Iowa prohibits discrimination in employment, educational programs, and activities on the basis of race, national origin, color, creed, religion, sex, age, disability, veteran status, sexual

orientation, gender identity, or associational preference. The University also affirms its commitment to providing equal opportunities and equal access to University facilities. For additional information on nondiscrimination policies, contact the Office of Equal Opportunity and Diversity, (319) 335-0705 (voice) and (319) 335-0697 (text), 202 Jessup Hall, The University of Iowa, Iowa City, Iowa 52242-1316