Copy of Uniting for Change: Harnessing the Power of Community Partnerships for Health Equity & Literacy Registration (Pine Street Family Health Center - Kingston)

Thank you for planning to attend our seminar. We look forward to seeing you on at 9 AM on Wednesday, March 20th at Pine Street Family Health Center in Kingston . Please fill out the registration form below.

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1. Name

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2. Phone

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3. Zip Code

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4. County:

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5. Email

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6. Company/Organization

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7. Job title

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8. Race:

Black/African American

Native American/Alaskan

Asian

Native Hawaiian/Pacific Islander

White

More Than One Race

Choose not to respond

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9. Ethnicity:

Hispanic

Non-Hispanic

Choose not to respond

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10. Gender:

Female

Male

Gender Non-Conforming

Choose not to respond

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11. Age:

≤ 19

20-29

30-39

40-49

50-59

≥ 60

Copy of Uniting for Change: Harnessing the Power of Community Partnerships for Health Equity & Literacy Registration (Pine Street Family Health Center - Kingston)

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* 1. Name

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* 2. Phone

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* 3. Zip Code

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* 4. County:

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* 5. Email

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* 6. Company/Organization

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* 7. Job title

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* 8. Race:

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* 9. Ethnicity:

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* 10. Gender:

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* 11. Age:

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* 12. Submit any questions for the seminar here

1. Name

2. Phone

3. Zip Code

4. County:

5. Email

6. Company/Organization

7. Job title

8. Race:

9. Ethnicity:

10. Gender:

11. Age:

12. Submit any questions for the seminar here