Community Connections Forum on Building a Resilient Community- Los Angeles

You are cordially invited to join Health Net in partnership with

Boys & Girls Clubs of Metro Los Angeles, Black Women for Wellness,
Charles R. Drew University, Martin Luther King, Jr. Community Hospital
and Watts Health

for its Community Connections Forum
focused on building a resilient community.

Breakfast will be provided. There is no charge to attend.

Friday, September 21, 2018 | 9:00 a.m. to 12:00 p.m.

Check-in and Reception starts at 8:30 a.m.

Boys & Girls Clubs of Metro Los Angeles Watts/Willowbrook
1339 E 120th St, Los Angeles, CA 90059

Please register before Wednesday, September 19.

For more information, contact Sandra Simpson at 916-246-3643 or sandra.p.simpson@healthnet.com

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* 1. First Name

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* 2. Last Name

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* 3. Job Title

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* 4. Organization

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* 5. Email

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* 6. Phone

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* 7. Address

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* 8. City

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* 9. State

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* 10. Zip

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* 11. How did you hear about the Community Connections Forum? (select answer that best applies.)

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* 12. Please let us know if you require any special seating or dietary accommodations:

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* 13. Health Net will be taking photographs at the Community Connections Forum for both external and internal use. Please review the statement below and select your answer.

I agree to give to Centene Corporation and its related companies (“Centene”), the right to use my name, voice, and appearance; and the right to use audio/visual recordings, verbal recordings, written statements, pictures, portraits, photographs, and any other image of me, biographical or occupational descriptions or phrases regarding me, and incidents, quotes, or stories concerning me (the “Material”), in any and all manner and media for the purpose of advertising, publicity, promotion and other purposes, now and for any future use.

I agree that Centene is the owner of the Material and Centene may edit, reproduce, prepare derivatives of, distribute, perform, display, transfer and copyright the Material without additional consent from me or payment to me. I expressly release Centene from any and all claims which I have or may have for invasion of privacy, defamation or any other cause of action arising out of any and all uses of the Material.

No promise or representation which is not expressed in this Consent and Release has been made to me, and I have read this document, understand it and am signing it voluntarily. This consent is voluntary and may be revoked at any time, provided written notice is sent to: Health Net Communications (CA-102-22-07), 21650 Oxnard St. Woodland Hills, CA 91344. Such revocation shall not apply to any Material currently in the public domain.

Please select one: