Event Registration Form

Join us at our 2024 Wisconsin Community Health Worker Network Conference on October 22 and October 23. Sponsored by:

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First Name (Required.)

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Last Name (Required.)

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Email

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Address

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What is your racial or ethnic identity? (Select all that apply.)

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Phone Number 

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Are you employed, contracted or a volunteer?

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If yes, what is the name of the Company/Organization and position title?

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What days do you plan on attending the event?

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Do you follow any of these dietary restrictions? (Please select all that apply.)

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Are you a formally trained Community Health Worker?

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Name of CHW training program.

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Date of Completion.

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