Exit CPCA HealthManagement+ Cohort 17 Application Personal and Professional Information Question Title * 1. First Name Question Title * 2. Last Name Question Title * 3. Preferred Pronouns Question Title * 4. Organization Name Question Title * 5. Title Question Title * 6. Work Email Question Title * 7. Alternate Email Question Title * 8. Office Phone Number Question Title * 9. Cell Phone Number Question Title * 10. Organization Contact Information Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: County: Website: Phone Number: Question Title * 11. Type of organization Non-profit Federally Qualified Health Center Question Title * 12. Years in current position 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25+ Question Title * 13. Years working in a community health center setting 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25+ Question Title * 14. Professional Affiliations, Memberships, Honors, Degree(s): Question Title * 15. Total number staff in organization Less than 10 11-25 26-50 50-100 101-200 201+ Question Title * 16. Number of staff you supervise 5 or less 6-10 11-15 16+ Question Title * 17. Number of volunteers you supervise 5 or less 6-10 11-20 21-50 50+ Question Title * 18. Do you have any dietary restrictions? We would like to know so we can make every attempt to accommodate your needs if we are able to host an in-person session in the future. Next