Please complete this survey to register for one of the 2018 town hall meetings to discuss the Michigan Mother Infant Health Improvement Plan.

*We are at max capacity for one of the Southeast town hall locations, the Henry Ford Health System - 1 Ford Place*

First and Last Name:

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* 1. First and Last Name:

Will you be attending additional meetings?

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* 3. Will you be attending additional meetings?

Please provide your email to receive directions and parking information:

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* 4. Please provide your email to receive directions and parking information:

Which category best describes you? Please select all that apply

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* 5. Which category best describes you? Please select all that apply

If applicable, institution/organization:

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* 6. If applicable, institution/organization:

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