MyHealth Matters CDSM Workshop Registration
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1. The Basics

PLEASE MAKE A NOTE OF THIS INFORMATION

Chronic Disease Self-Management (CDSM) Workshop
Wednesday evenings, 6:00pm-8:30pm
Thurston County Public Health and Social Services Department
412 Lilly Road NE, Olympia, WA 98506

*Funding provided by Lewis-Mason-Thurston Area Agency on Aging

1. Which workshop do you plan to attend?

Which workshop do you plan to attend? September 26th - October 31, 2012

2. Name

Name Last
First
MI

3. Address

Address House #, Street
City
ST
Zip

4. Contact information (please provide at least one phone number)

Contact information (please provide at least one phone number) Home
Cell
Work
Email

5. Best way to reach you

Best way to reach you Home phone

Cell phone

Work phone

No preference

Please note any specific time frames

6. Emergency contact

Emergency contact Name
Phone
Relationship

MyHealth Matters CDSM Workshop RegistrationExit this survey

1. The Basics

MyHealth Matters CDSM Workshop Registration
Exit this survey