Personal and Professional Information


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* 1. First Name

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* 2. Last Name

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* 3. First & Last Name (as you would like shown on your name tag)

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* 4. Organization Name

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* 5. Title

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* 6. Work Email

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* 7. Alternate Email

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* 8. Office Phone Number

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* 9. Cell Phone Number

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* 10. Organization Contact Information

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* 11. Type of Organization

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* 12. Years in current position

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* 13. Years working in a community health center setting

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* 14. Certifications, Professional Affiliations, Memberships, Honors, Degree(s)

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* 15. Number of staff you supervise (if applicable)

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* 16. Number of volunteers you supervise (if applicable)

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* 17. Do you have any dietary restrictions? We would like to be able to accommodate you during in-person sessions if possible.

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