Sign Up to Participate in Pueblo's Public Health Emergency Dispensing Exercise

Welcome & Thank you for signing up!

The information collected is to plan for community participation in the June 17, 2017 Pueblo Public Health Emergency Dispensing Exercise.

The information provided here will be used for this event only.

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* 1. What is your name? (Last, First)

Last Name

First Name

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* 2. What is the best method to contact you? (a reminder notification will be sent to you)

Email

Text

Telephone

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* 3. Based on the best method to contact you, provide that information (e.g. email address, cell phone number and provider: Verizon, T-Mobile, Sprint, etc., or telephone number). A reminder will be sent to your preferred method of contact.

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* 4. Do you plan to bring others with you, if so, how many?