*1.Please provide the following information:(Required.)

Name

Organization

Organization Mailing Address

Address 2

Organization City/Town

State/Province

Organization ZIP/Postal Code

County

Participant Email Address

Participant Phone Number

*2.Please identify your organization. This is not an exhaustive list, so if needed, write in your information in other.(Required.)

Baptist

Methodist

Lutheran

Presbyterian

Episcopal

Catholic

COGIC

Assembly of God

Jewish

Muslim

Mormon

Non-denominational

Other (please specify)

3.If you have questions you would like answered during the conference, please feel free to add them here.  If not, you can ask via the chat on 4/28/22.

*4.Does your organization have a health ministry/committee(Required.)

Yes

No

5.If your organization has a health ministry or desires to create one, the Durham County Health Ministry Network is a wonderful resource to start and sustain your efforts.  Are you interested in joining or learning more?

Yes

No

My organization is not located in Durham County

*6.Great! We love that you are interested in the Durham County Health Ministry! Please answer the questions below and we will follow up.(Required.)

Name

Email Address

Phone Number