Alliance Registration Oct 17 Please Register to Attend the CHW PN PdS Alliance Meeting Question Title * 1. General Information Name Organization Position/Title Address City/Town State/Province ZIP/Postal Code Email Address Phone Number Question Title * 2. I will be attending the October 17, 1-3p CHW PN PdS Meeting Yes, in person in Metro Denver Yes, remotely via web (not in person) Yes, remotely and if possible at a watch party outside of Denver (locations TBD) Yes, but not sure if in person or via web connection No, but keep me on the distribution list No, please remove me from the distribution list Other (please specify) Question Title * 3. The following Health Service Regions are where I focus/provide my CHW PN and PdS Efforts (choose all that apply) HSR 1: Logan, Morgan, Phillips, Sedgwick, Washington and Yuma Counties HSR 2: Larimer County HSR 3: Douglas County HSR 4: El Paso County HSR 5: Cheyenne, Elbert, Kit Carson and Lincoln Counties HSR 6: Baca, Bent, Crowley, Huerfano, Kiowa, Las Animas, Otero and Prowers counties HSR 7: Pueblo County HSR 8: Alamosa, Conejos, Costilla, Mineral, Rio Grande and Saguache counties HSR 9: Archuleta, Dolores, La Plata, Montezuma and San Juan counties HSR 10: Delta, Gunnison, Hinsdale, Montrose, Ouray and San Miguel counties HSR 11: Jackson, Moffat, Rio Blanco and Routt counties HSR 12: Eagle, Garfield, Grand, Pitkin and Summit counties HSR 13: Chaffee, Custer, Fremont and Lake counties HSR 14: Adams County HSR 15: Arapahoe County HSR 16: Boulder and Broomfield counties HSR 17: Clear Creek, Gilpin, Park and Teller counties HSR 18: Weld County HSR 19: Mesa County HSR 20: Denver County HSR 21: Jefferson County All HSR in Colorado Other (please specify) Question Title * 4. Comments or Questions Done