Exit Living Well Thurston Registration Form Summer 2024 Title: Living Well Thurston WorkshopWhen: Wednesdays, July 31 to September 11, 2024 from 1:00pm - 3:30pmTo Register: Fill out the information belowThank you for registering for a Living Well Thurston workshop! Thurston County Public Health and Social Services is pleased to offer this workshop for free to the community. There is no cost to register or attend. For more information, contact Lesley Price at (360) 480-4654 or LivingWellThurston@co.thurston.wa.us. Question Title * 1. First and Last Name: Question Title * 2. Date of Birth Please enter your date of birth in MM/DD/YYYY format. Date Question Title * 3. Contact Information: Mailing Address Mailing City Mailing State Mailing Zip Code Phone Number Email Address Question Title * 4. Which of the following describes why you are attending this workshop? Select all that apply. To address your chronic health condition To support someone else who has a chronic health condition Other, please describe Question Title * 5. What are one or two things you hope to gain from this workshop? Question Title * 6. The workshop is offered online. Do you have the ability to use Zoom on a laptop or desktop computer with a webcam, microphone, speakers/headphones, and stable internet connection? (Smart phones and tablets are not allowed.) No Yes Question Title * 7. How did you first hear about the workshop? Social Media Thurston County Website Flyer Radio ad Church Senior Center Health Care Provider News Article Workplace Email Other Email Friend or Family Presentation Community Event Other (please specify) Question Title * 8. Do you currently have health insurance? No Yes, Medicaid or Apple Health Yes, Medicare Yes, employer provided insurance Yes, some other kind of insurance Prefer not to say Question Title * 9. What is your age? 18-34 35-49 50-64 65+ Prefer not to say Question Title * 10. How do you describe your race? Select all that apply. American Indian or Alaskan Native Asian or Asian American Black or African American Native Hawaiian or other Pacific Islander White Middle Eastern or Northern African Prefer not to say Other (please specify) Question Title * 11. How do you describe your ethnicity? Of Hispanic/Latino/Spanish origin Not of Hispanic/Latino/Spanish origin Prefer not to say Question Title * 12. Do you usually speak a language other than English at home? Prefer not to say No Yes (If yes, what is the language usually spoken at home?) Question Title * 13. Below is a list of terms that people may use to describe their gender identity. Select all that apply. Man Woman Transgender man Transgender woman Nonbinary Questioning/Not sure of my gender identity Something else fits better Prefer not to say Question Title * 14. What is your highest level of education? High school diploma GED Associate's degree Bachelor's degree Master's degree Professional degree Doctorate degree Trade/technical/vocational school Prefer not to say Other (please specify) Question Title * 15. What is your current employment status? Full-time Part-time Unemployed Unemployed but seeking job opportunities Retired Prefer not to say Other (please specify) To complete this registration, please click "Submit." Submit