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Event Registration Form

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

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* First Name

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* Last Name

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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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