Addressing Mental Health Disparities in Hispanic-Latino/a/x Communities in Northeast Georgia

Registration

In order to continue to provide CME/CE webinars and other resources such as this, we need information from you. Please complete this brief registration form to gain access to the CME/CE webinar Addressing Mental Health Disparities in Hispanic-Latino/a/x Communities in Northeast Georgia. Upon completion, you will receive the link to the recorded webinar.

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* 1. First and last name

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* 2. Email address

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* 3. Are you a student? If yes, please include school name, degree program, and expected graduation date.

Yes

School name, degree program, and expected graduation date:

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* 4. Employer

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* 5. Job title and/or credentials

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* 6. Organization/Employer County

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* 7. Permanent Residence County

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* 8. Does your employer accept Medicaid?

Yes

N/A or unknown

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* 9. Does your employer accept Medicare?

Yes

N/A or unknown

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* 10. Age

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* 11. Gender

Male

Female

Other

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* 12. Race

African American

Asian

Caucasian

Hispanic

Native American

Pacific Islander

More than one race

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* 13. Ethnicity

Hispanic-Latino/a/x

Non-Hispanic-Latino/a/x

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* 14. Does this program apply to employer, state licensure, or certification requirements?

Yes

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* 15. Are you a current or past recipient of National Health Service Corp (NHSC) Funds?

Yes