Thank you for your interest in the Town Hall with Dr. Joseph Betancourt. Please complete the following questions and submit to RSVP for the event.

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* 1. First Name

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* 2. Last Name

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* 3. Email address

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* 4. What is your occupation (check all that apply)?

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

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* 6. Do you require wheelchair accessible seating?

We are collecting demographic information about our attendees to help us know them better.  We can better meet the needs of our communities if we know more about our attendees and their culture.  This information is private and you do not need to share this information to register.

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* 7. Please describe your ethnicity (select 1)

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* 8. Please describe your race (Please select all that apply)

Submitting this form completes your RSVP.  For any questions, you may contact disparitiessolutions@partners.org

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