Daring Dialogue Participant Registration

Daring Dialogue Participant Registration

Thank you for your interest in joining a Daring Dialogue!
Select your municipality*
Name *

First NameLast Name
Professional Title or Role in the Community*
Employer or Organization*
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Select your role in the community (check all that apply)*

Resident with Lived Experience in AgeismResident with Lived Experience in AbleismCare PartnerMunicipal Leader (Volunteer)Municipal Leader (Employee)Connecticut Community Care EmployeeOther
Do you need any ADA accommodations?*

NoYes
The following ingredients may be present in the food service establishment preparing food offered at this event: milk ~ eggs ~ fish ~ tree nuts ~ peanuts ~ wheat ~ soybean ~ crustaceans ~ sesame*

I understand
This program is scheduled for Thursday, June 6, 2024. The timing will be decided based on participant preference and availability. What time(s) are you available on June 6? Select all that apply.*

10:00am-12:30pm2:00pm-4:30pm
Demographic Data (Optional)

Demographic data helps the Connecticut Age Well Collaborative recruit diverse participation and understand who will be participating in the workshop. The following questions are HIPAA compliant and will not be shared.
What is your age range?

I prefer not to answer100+90-9980-8970-7960-6950-5940-4930-3918-29
Do you have a disability?

I prefer not to answerNo, I do not have a disabilityYes, physicalYes, emotionalYes, cognitiveYes, sensoryYes, multiple types
What is your race?

I prefer not to answerAsianBlack/African AmericanHispanic/ Latino/a/xNative AmericanPacific IslanderWhiteMulti-Racial
What is your gender?

I prefer not to answerManWomanTransgender manTransgender womanI prefer to self-describe
Do you identify as a member of the LGBTQIA++ community?

I prefer not to answerYesNoI'm not sure
Do you have any feedback or suggestions on this registration form?

NoYes
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Daring Dialogue Participant Registration

Demographic Data (Optional)