October 2026: Environmental Health & Community Futures Registration Form

October 24th, 2026

1:00pm-2:00pm ET

Question Title

1. First Name (Required.)

Question Title

2. Last Name (Required.)

Question Title

3. Email (Required.)

Question Title

4. Phone Number (Required.)

Question Title

5. Age (Required.)

Under 18

18-24

25-34

35-44

45-54

55-64

65-74

75 years or older

Question Title

6. Gender (Required.)

Male

Female

Non-Binary

Prefer not to specify

Prefer to Self-Describe:

Question Title

7. Race/Ethnicity (please check all that apply) (Required.)

Asian / Pacific Islander

Black or African American

Hispanic or Latinx

Native American or American Indigenous

White

Other Race

Prefer not to specify

Unknown/Undetermined

Question Title

8. City and State of Residence (Required.)

Question Title

9. On a scale from 1 to 7, how knowledgeable are you about environmental health? (Required.)

1-Not at all knowledgeable

4-Somewhat knowledgeable

7-Extremely knowledgeable

Not sure

1-Not at all knowledgeable

4-Somewhat knowledgeable

7-Extremely knowledgeable

Not sure

Question Title

10. On a scale from 1 to 7, how knowledgeable are you about community engagement & empowerment? (Required.)

1-Not at all knowledgeable

4-Somewhat knowledgeable

7-Extremely knowledgeable

Not sure

1-Not at all knowledgeable

4-Somewhat knowledgeable

7-Extremely knowledgeable

Not sure

Question Title

11. Are you interested in participating in this month's healthy challenge?

Yes

October 2026: Environmental Health & Community Futures Registration Form

Question Title

* 1. First Name (Required.)

Question Title

* 2. Last Name (Required.)

Question Title

* 3. Email (Required.)

Question Title

* 4. Phone Number (Required.)

Question Title

* 5. Age (Required.)

Question Title

* 6. Gender (Required.)

Question Title

* 7. Race/Ethnicity (please check all that apply) (Required.)

Question Title

* 8. City and State of Residence (Required.)

Question Title

* 9. On a scale from 1 to 7, how knowledgeable are you about environmental health? (Required.)

Question Title

* 10. On a scale from 1 to 7, how knowledgeable are you about community engagement & empowerment? (Required.)

Question Title

* 11. Are you interested in participating in this month's healthy challenge?

Question Title

* 12. If you would like to receive a wellness give-away, please provide an address where you would like us to send your items.

1. First Name (Required.)

2. Last Name (Required.)

3. Email (Required.)

4. Phone Number (Required.)

5. Age (Required.)

6. Gender (Required.)

7. Race/Ethnicity (please check all that apply) (Required.)

8. City and State of Residence (Required.)

9. On a scale from 1 to 7, how knowledgeable are you about environmental health? (Required.)

10. On a scale from 1 to 7, how knowledgeable are you about community engagement & empowerment? (Required.)

11. Are you interested in participating in this month's healthy challenge?

12. If you would like to receive a wellness give-away, please provide an address where you would like us to send your items.