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Stroke Smart Michigan Partner Interest Form
Please complete the information below. The Michigan Stroke Program will contact you to schedule a 15 minute meeting to discuss your participation and the resources your organization will need to become recognized as Stroke Smart.
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1.
Name
(Required.)
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2.
Email Address
(Required.)
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3.
Phone Number
(Required.)
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4.
Which type of organization are you affiliated with?
(Required.)
Faith-based organization
Skilled nursing facility
Business
Community-based organization (shelter, food pantry, neighborhood associations, etc.)
Pharmacy
Senior center
Elementary school
Middle school
High school
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5.
What is the name and address of the organization?
(Required.)
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6.
Approximately how many people does your organization serve?
(Required.)
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7.
Do you or your organization require any accommodations in accordance with the Americans with Disabilities Act (ADA) to ensure all individuals are able to participate in the program?
(Required.)
Yes
No
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8.
If you answered "yes" to the previous question please describe the accommodations needed.
(Required.)
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9.
How did you hear about the Stroke Smart Michigan program?
(Required.)