CHIPP Pilot Site Informational Session

An informational conference call on the CHIPP pilot site opportunity will be held on March 1 from 1:00-2:00 p.m. The call will be recorded for later listening as well. The recording information will be posted on www.walhdab.org/CHIPPpilot.htm.

Please register for the call by providing us with your contact information. Additional details will be sent to you prior to the call.

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* 1. Name (last, first):

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* 2. Email:

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* 3. Agency type:

Local health department

Tribal health entity

Hospital

Clinic

United Way

School district

Other (please specify)

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* 4. Name of agency:

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* 5. I plan on attending the informational conference call:

At the time of the call

After the call occurs (listening to the recording)

Unsure

Note/Comment:

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* 1. Name (last, first):

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* 2. Email:

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* 3. Agency type:

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* 4. Name of agency:

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* 5. I plan on attending the informational conference call:

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* 6. At this time, I have these specific questions about the pilot site opportunity: