High Point, Guilford County PHEC Town Hall Registration Form

Perinatal Health Strategic Plan Town Hall, Attendee Registration Form

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* 1. First Name

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* 2. Last Name

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* 3. Email

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* 4. Phone Number (optional)

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* 5. Company/Organization

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* 6. What counties does your organization serve?

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* 7. Population Served by Organization (listed above)

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)

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* 8. Position Title

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* 9. How do you plan on attending the event?

In Person

Virtually

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* 10. How do you identify yourself?

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)

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* 11. Will you need any special accommodations to fully participate in this event?

Spanish Translation

Sign Language Interpreter

Closed Captions

Other (please specify)

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* 12. Prior to learning of this event, were you aware of the Perinatal Strategic Health Plan?

Yes