Building CHW skills: Encouraging health promotion and Covid 19 prevention
Registration Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Name of Organization/Employer
*
I am a Community Health Worker
Please select an option from the dropdown
yes
no
Number of clients you serve
*
Zip codes you primarily serve
*
Please select your 1st choice of dates
*
Please select from the drop down box
February 16 and 23, 12-2pm CST
March 21 and 28, 10am-12pm CST
Please select your 2nd choice of dates
*
Please select from the drop down box
October 5 and 12, 12-2pm CST
November 3 and 10, 2-4pm CST
Please select your 3rd choice of dates
*
Please select from the drop down box
September 15 and 22, 10-12am CST
October 5 and 12, 12-2pm CST
November 3 and 10, 2-4pm CST
Submit
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