Please indicate your willingness to be part of a team of educators informing various community members throughout the Fingerlakes Region about COVID and vaccination. Common Ground Health can provide power point presentations and standardized educational materials for you.

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* 1. Preferred Title

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* 2. Full Name

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* 3. Mobile Phone Number 

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* 4. Office Phone Number

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* 5. Preferred E-Mail Address

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* 6. Organization Affiliation(s) 

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* 7. Speciality or Field(s) of Practice or Interests 

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* 8. What is your race / ethnicity? (check all that apply) 

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* 9. What is your gender?

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* 10. What type of education do you feel comfortable providing? (check all that apply)

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* 11. What is your general availability?

  Mornings (between 9am and 12pm) Lunch hour (between 12pm and 1pm) Afternoon (between 1pm and 5pm) Evening (between 5pm and 8 pm)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

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* 12. What credentials do you have?

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* 13. What other presentation or teaching experience do you have?

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* 14. What population(s) are you interested in serving? (Check all that apply, and use the "other" option to clarify or add any additional groups not represented below) 

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* 15. Do you speak any languages proficiently besides English? If so, please list them. 

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* 16. Please put anything else you would like for us to know about your ability to provide educational service to the community.

0 of 16 answered
 

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