*1.Please provide the following information:(Required.)

Name

Organization

Organization Mailing Address

Organization City/Town

State/Province

Organization ZIP/Postal Code

County

Participant Email Address

Participant Phone Number

2.Do you have any dietary restrictions?

Yes

No

3.Please identify your dietary restrictions below.

Gluten-free

Kosher

Halal

Vegetarian

Vegan

Lactose intolerance or milk

Pescatarian

Peanut allergy

Shellfish

Other (please specify)

*4.Please identify your organization. This is not an exhaustive list, so if needed, write in your information in other.(Required.)

Baptist

Methodist

Lutheran

Presbyterian

Episcopal

Catholic

COGIC

Assembly of God

Jewish

Muslim

Mormon

Non-denominational

Other (please specify)

5.If you have questions you would like answered during the conference, please feel free to add them here. If not, feel free to do so the day of the event.

6.How did you hear about this event? (check all that apply)

Flyer or email sent to my organization

Social media (Facebook, Instagram etc.)

Flyer posted in the community

Email sent directly to me

Information provided by my faith-based organization

*7.At this time, we are prepared for participants who need interpretation (Spanish). Will you need this service?(Required.)

Yes

No

*8.Does your organization have a health ministry/committee(Required.)

Yes

No

9.If your organization has a health ministry or desires to create one, the Durham County Health Ministry Network is a wonderful resource to start and sustain your efforts.  Are you interested in joining or learning more?

Yes

No

My organization is not located in Durham County

10.Great! We love that you are interested in the Durham County Health Ministry! Please answer the questions below and we will follow up.

Name

Email Address

Phone Number