HEAL Zones January Convening Registration

Registration Information

Thank you for registering for Kaiser Permanente HEAL Zones Learning Community.

Please complete this registration by Wednesday, January 4, 2012. Each participant from your coalition must register individually.

You may leave this form at any time by closing your browser window or clicking "Exit this Survey," and your information will be saved, allowing you to re-enter at the point where you left off. To fully transmit your information to us, please go through to the end and click "Done" when you are finished.

If a second person will be using the same computer to enter their registration information, the first registrant must first click "Done," or his/her data will be overwritten.

Question Title

* 1. Name

First Name

Last Name

Title

Question Title

* 2. Contact information

Organization

Address

Address line 2

City

State

Zip

Phone

Fax

E-mail

Website

Question Title

* 3. Please indicate your primary affiliation:

Elementary school

Middle school

High school

School district

After-school program

Medical clinic

Department of public health

City government

County government

Faith based organization

Community based organization

Community resident

Kaiser Permanente staff

Other (please specify)