Webinar Registration

Please fill in your information to confirm your registration. You will be sent the confirmation email after we receive this form.

Please answer all questions with a (*)

Questions/concerns or if you prefer to register over phone:

Reach out to vzermeno@heraca.org or (510) 779-2975

Question Title

* 1. What is your first and last name?

Question Title

* 2. What is your phone number? (xxx-xxx-xxxx)

Question Title

* 3. What email address would you like us to send the webinar link?

Question Title

* 4. What is your zip code and city? (or NA if prefer not answer)

Question Title

* 5. Are you Hispanic/Latino?

Yes

Question Title

* 6. Which best describes your race?

White

Black or African American

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race/multiracial

Question Title

* 7. What best describes your gender?

Female

Male

Genderqueer/Gender non-binary

Other

Question Title

* 8. What is your marital status?

Single

Married

Divorced

Widowed

Domestic Partnership

Webinar Registration

Question Title

* 1. What is your first and last name?

Question Title

* 2. What is your phone number? (xxx-xxx-xxxx)

Question Title

* 3. What email address would you like us to send the webinar link?

Question Title

* 4. What is your zip code and city? (or NA if prefer not answer)

Question Title

* 5. Are you Hispanic/Latino?

Question Title

* 6. Which best describes your race?

Question Title

* 7. What best describes your gender?

Question Title

* 8. What is your marital status?

Question Title

* 9. Number of people in your household (including yourself)

Question Title

* 10. Total Gross Monthly Income