RESTORE Disaster Preparedness Training Registration November 21, 2019

Location
Florida International University - Emergency Operations Center
885 SW 109th Ave, Miam

Time: 8:30am-5:00pm

Question Title

* 1. Name

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* 2. Organization

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* 3. Organization Address

Address

City/Town

State/Province

ZIP/Postal Code

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* 4. Email

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* 5. Cell Phone Number

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* 6. Work Phone Number

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* 7. Home Zip Code

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* 8. Ethnicity

Hispanic

Non-Hispanic

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* 9. Race

White

Black

Asian/Pacific Islander

American Indian or Alaska Native

Other

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* 10. Gender

Female

Male

Transgender

Other

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* 11. Please select the age range that best describes you.

18-24

25-34

35-44

45-54

55-64

65-74

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* 12. Are you currently a Certified Community Health Worker (CCHW)? (Certification is NOT required to participate)

Yes

RESTORE Disaster Preparedness Training Registration November 21, 2019

LocationFlorida International University - Emergency Operations Center885 SW 109th Ave, Miam

Question Title

* 1. Name

Question Title

* 2. Organization

Question Title

* 3. Organization Address

Question Title

* 4. Email

Question Title

* 5. Cell Phone Number

Question Title

* 6. Work Phone Number

Question Title

* 7. Home Zip Code

Question Title

* 8. Ethnicity

Question Title

* 9. Race

Question Title

* 10. Gender

Question Title

* 11. Please select the age range that best describes you.

Question Title

* 12. Are you currently a Certified Community Health Worker (CCHW)? (Certification is NOT required to participate)

Location
Florida International University - Emergency Operations Center
885 SW 109th Ave, Miam