Call for Applications: Healthy, Happy Teams

Practice information

Please complete all questions in this call for applications to apply to the "Healthy, Happy Teams" project.

To view the full call for applications, which provides more details about the program, click this link.

Question Title

* 1. Name of your practice

Question Title

* 2. Practice address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Question Title

* 3. Practice Tax ID number

Question Title

* 4. Type of Practice

Pediatric

Family/Internal Medicine

FQHC

Other (please specify)

Question Title

* 5. Primary Contact person for this project

Name

Title

Professional Credential (MD, DO, etc.)

Email Address

Phone number