EmailMe Form - 2025 Structured Family Recovery(R) Registration:

Registrant's Name *

First Last

Additional Attendees (s)

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Email *

Relationship:
Please indicate your relationship with the individual, if they have a diagnosis or any other information that would be helpful. This section is limited to 200 words. *

**If you are related to someone 21 years or younger, we recommend you to enroll in our NAMI Basics course.

Emergency Contact Name *

First Last

Emergency contact relationship to registrant

Emergency Contact Phone Number *

### - ### - ####

Date *

MM / DD / YYYY

Name of Person Completing Registration Form *

First Last

Email Address of Person Completing Registration Form *

How did you find out about NAMI Emerald Coast?