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WA Geriatric Healthcare Series: Profile Form

Spring 2020

Please register for the Geriatric Healthcare Series Spring 2020 by filling out this form. There will not be a confirmation email, but you will receive weekly emails of each coming lecture from your state coordinator.

Should you have any problems filling out this form, please email nwgwec@uw.edu. 
1.What entity are you participating from?(Required.)
2.What's your name (first and last)?(Required.)
3.Your credentials / degree(s) (eg: RN, DO, ARNP)?(Required.)
4.Name of your current employer:(Required.)
5.What's your current health profession? (based on funding agency categories, please choose the one that best fits your profession)(Required.)
6.What's your email address?(Required.)
7.Please select if any of the following is true (mark all that apply):(Required.)
8.Do you currently work in a (mark all that apply):(Required.)