CHNA Forum Registration - Lincoln County

3pm Refreshments/Sign-In; 3:30pm-5:30pm Forum
Lincoln Academy, 81 Academy Hill, Newcastle, ME

We invite you to join us in conversation at the Lincoln County Community Health Needs Assessment (CHNA) forum. Come share your thoughts on the health priorities of our community.

Partnering Organizations: LincolnHealth, Healthy Lincoln County and Midcoast Public Health Council, with support and guidance from the Maine Shared CHNA collaboration partners: Central Maine Healthcare, EMHS, MaineGeneral Health, MaineHealth, and the Maine Center for Disease Control and Prevention.

Question Title

* 1. Please tell us about yourself. (Your name may be used for a name badge.)

First and Last Name

Organization or Business

Address

Address 2

City/Town

State

Zip Code

Email Address

Phone Number

Question Title

* 2. RSVP

Yes, I plan to come to the forum on Tues, Nov 13, 2018 at Lincoln Academy.

No, I cannot attend. (Please feel free to share this email with others and/or send a representative.)

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* 3. Which community sector do you represent?

Business

Community Member

Education

Healthcare

Non-profit organization

Faith-Based

Public Health

Social Services

Other (please specify)

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* 4. I understand that my name, photograph, voice or likeness may be used for all promotional purposes related only to the Community Forum by any of the Partnering Event Organizers and their sponsors, beneficiaries, licensees, affiliates and employees. I consent to and authorize, in advance, such use and waive all rights of privacy I have in connection therewith. I also understand that I will not be entitled to any payment or other form of compensation from any use thereof.

I understand and agree to the above statement.

I do not wish to have any images or likeness of myself published in any reports.

Thank you.