High Point, Guilford County PHEC Town Hall Registration Form
Perinatal Health Strategic Plan Town Hall, Attendee Registration Form
*
1.
First Name
(Required.)
*
2.
Last Name
(Required.)
*
3.
Email
(Required.)
4.
Phone Number (optional)
*
5.
Company/Organization
(Required.)
*
6.
What counties does your organization serve?
(Required.)
*
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)
8.
Position Title
*
9.
How do you plan on attending the event?
(Required.)
In Person
Virtually
*
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)
11.
Will you need any special accommodations to fully participate in this event?
Spanish Translation
Sign Language Interpreter
Closed Captions
Other (please specify)
*
12.
Prior to learning of this event, were you aware of the Perinatal Strategic Health Plan?
(Required.)
Yes
No