Carrboro, Chatham County PHEC Town Hall Registration Form Perinatal Health Strategic Plan Town Hall, Attendee Registration Form Question Title * 1. First Name (Required.) Question Title * 2. Last Name (Required.) Question Title * 3. Email (Required.) Question Title * 4. Phone Number (optional) Question Title * 5. Company/Organization (Required.) Question Title * 6. What counties does your organization serve? (Required.) Question Title * 7. Population Served by Organization (listed above) (Required.) Young Children Pregnant/Birthing People Caregivers of Small Children Families with Young Children Uninsured Individuals Unhoused/Individuals Experiencing Homelessness LGBTQ+ Native/Indigenous Communities Immigrant and/or Migrant Families Other (please specify) Question Title * 8. Position Title Question Title * 9. How do you plan on attending the event? (Required.) In Person Virtually Question Title * 10. How do you identify yourself? (Required.) Person of Reproductive Age Parent Parent of Small Child(ren) (under the age of 5) Parent Advocate Clinical Provider Non-medical Care Provider Community Based Birthworker Community Activist Policy Advocate Local Community Member Other (please specify) Question Title * 11. Will you need any special accommodations to fully participate in this event? Spanish Translation Sign Language Interpreter Closed Captions Other (please specify) Question Title * 12. Prior to learning of this event, were you aware of the Perinatal Strategic Health Plan? (Required.) Yes No Done