CleanAIRE NC Health Sign-Up form

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Thank you for your interest in joining CleanAIRE NC's Health community. We provide resources and training to help health professionals discuss climate change and air pollution with their patients and in the communities they serve, and to advocate for equitable solutions that improve health in our communities, now and for future generations.

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電子郵件 *

First Name *

Last Name *

Email address *

Are you a health professional? *

Yes

Occupation *

Public Health Practitioner

Physician

Nurse

Respiratory Therapist

Pharmacist

Physician Assistant

Dentist

Social Worker

Academic Researcher

Educator

Graduate Student (i.e. MPH, MS, etc.)

Doctoral Candidate

其他：

必填

Specialty

Organization/Employer

City of Residence *

Zip Code *

Phone Number

Race/Ethnicity - check all that apply (we collect this data to evaluate our diversity, equity, and inclusion efforts)

American Indian/Alaska Native/Native American/Indigenous

Asian/Asian American/Pacific Islander

Black/African American/African

Hispanic/Latino/Latina/Latinx

Multi-racial or Multi-ethnic

White/Caucasian/European

Prefer not to say

其他：

Preferred Pronouns

Health Advisory Board General Responsibilities

CleanAIRE NC's Health Advisory Board members are volunteer leaders who strongly commit to advocating for equitable solutions to air pollution and climate change. They guide and support Health initiatives and help recruit, educate, and engage health professionals in CleanAIRE NC programming efforts, including air quality and climate change campaigns.

How would you like to get involved in CleanAIRE NC's Health program? *

I am interested in joining the Health program as a general member to learn more of how I can make a difference in my community

I am interested in joining the Health program as a Advisory Board member to lead changes by attending quarterly meetings.

I just want to get emails to stay up to date with the issues and your work.

其他：

I am interested in the following action teams (check all that apply)

Education: I want to learn more about how air pollution and climate change exacerbate health inequities so I can improve how I provide care

Advocacy Training: I want to learn more about how I can leverage my voice as a healthcare professional to advocate for equitable policies that promote public health

Environmental Justice: I want to learn more about communities most impacted by air pollution and climate change to advance health equity

其他：

How did you hear about us?

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