Social Risk Factors: Food Insecurity Learning Collaborative

Question Title

* 1. What is your first name?

Question Title

* 2. What is your last name?

Question Title

* 3. What is your title at your health center/organization?

Question Title

* 4. Please list any healthcare credentials you hold. Ex: RN, RD, etc.

Question Title

* 5. Are you currently employed by a heath center?

Yes

No

Question Title

* 6. What is the name of your health center or organization?

Question Title

* 7. Please provide your health center/organization address, including city, state, and zip code.

Question Title

* 8. Is there a second address you would like to include?

Question Title

* 9. What is your email address?

Question Title

* 10. Do you currently have a Food RX/Food Prescription program in place at your health center/organization?

Yes

No

No, but interested in learning more to implement one

Question Title

* 11. We ask that you commit to participating in all learning sessions in order to register for this Learning Collaborative. By checking the box below, you indicate your commitment to participating in all sessions.
There will be 4 sessions held from 12-1:30pm CST on the following dates:
February 6
February 13
February 20
February 27

Yes, I commit to taking part in all learning sessions.

Question Title

* 12. Supervisor approval is required for participation in this Learning Collaborative. By checking the box below, you indicate that you have received approval from a supervisor.

Yes, I have received supervisor approval to participate.

Question Title

* 13. Would you like to be added to the NCFH mailing list to learn more about NCFH services and upcoming events?

Yes, please.

No, thank you.

I am already on the list.