July 12th, 2023 L(earn)/Lunch Attestation Form

Participation Statement*
I participated in the training Suicide Prevention in Pediatric Primary Care with Lia Gaggino, MD on July 12th, 2023 from 12:00pm-1:00pm PT. Please accept this as verification that I participated in the event in its entirety.
- I have read and agree to the statement above.
Name
First Last
Profession/Discipline:
On the line below, please enter your full name and licensure, EXACTLY as you would like it to appear on your CE certificate.*
Example: Jane Doe, PhD, CADC I
Hidden
I confirm the single line above contains my name and licensure exactly as I want displayed on my CE certificate.
- Yes, I confirm that the line above contains exactly what will be shown on my CE certificate.
Email address where you would like your CE certificate delivered.*
Enter Email Confirm Email
Can we send you information about upcoming trainings?
- Yes
- No
Signature*
By signing below, I verify that I attended this event in its entirety.

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