Exit this survey >> Webinar Registration Engagement of Family Leader Organizations in Non-CSHCN Initiatives March 26, 2015, 3:00-4:00pm ET Question Title * 1. Please enter the following information: Name: * Organization: Title: State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming Email Address: * Phone Number: * Question Title * 2. (Optional) Please indicate your race: American Indian or Alaskan Native Asian Black Pacific Islander White Other Race Question Title * 3. (Optional) Is your ethnicity Latino or Hispanic? Yes No Question Title * 4. (Optional) Please indicate your primary language: English Spanish Other: Question Title * 5. Please indicate your primary role in participating in this webinar. (Family Leaders may choose "Parent/Family") Parent/Family Other Consumer of Health Services Community-Based/Local Organization Staff Health Provider/Professional Education Provider/Professional State MCH Agency Staff Other (please specify) Question Title * 6. Please indicate the number of additional people who will share your call line and/or webinar screen. (We are interested in the total number of participants, not only the number who register or log on): Question Title * 7. Please let us know any specific questions you have about this topic: Question Title * 8. Family Voices has free e-newsletters to help keep you informed about issues important to you. Washington DC Update is a weekly newsletter that compiles the latest news in national policy affecting CYSHCN; upcoming webinars related to serving CYSHCN and their families; and update and resources related to the ACA, and more. Friday's Child is a quarterly newsletter containing articles and information for family leaders and professionals on topics such as leadership, mentoring, and partnering. Resource eBlast is a monthly collection of links to new health resources for families. Select the appropriate box(es) below to sign up: Washington DC Update Friday's Child Resource eBlast None I am already signed up for what I want to receive Comments (optional): Thank you! After clicking the "Done" button, you will be redirected to a PDF containing webinar connection information. Please save the information for reference on the day of the webinar. Done >>
