East Texas Recovery Forum Registration

Please use the form below to register for the East Texas Recovery Forum to be held Monday, August 12, 2013, at UT-Health Northeast from 9 am - 4 pm (registration at 8 am).

Question Title

* 1. Please enter your contact information below.

First Name:

Last Name:

Address:

City:

State:

ZIP:

Home Phone:

Cell Phone:

E-mail:

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* 2. Affiliation:

Professional Provider

SA Treatment

MH Treatment

SA Prevention

Faith-Based

Housing

Food Pantry

Employment

Volunteer

Transportation

Legal

Criminal Justice

Peer Coach

Education

Health

Finance

Family Peer

Other (please specify)

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* 3. Please indicate if you are interested joining a carpool or vanpool to this event or providing such a service:

Would like to join a carpool/vanpool

Would consider providing a carpool/vanpool

Other (please specify)