JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
“Perinatal Roundtable: Inclusive Language”
Registration for the July 13, 2022 webinar “Perinatal Roundtable:Inclusive Language” This webinar will take place from 12-1pm. within a few days of your response submission you will receive a Zoom link. If you have any questions please email Tim Hudson (
hudsonti@med.umich.edu
)
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
1. First Name
*
Your answer
2. Last Name
*
Your answer
3. Provider Role (physician, social work, etc.)
*
Your answer
4. Which organization are you with?
*
Your answer
5. What is the location of your organization?
*
Your answer
6. Which county is your organization located in? (Example: Grand Traverse, Alcona, Wexford, etc)
*
Your answer
7. How did you hear about this webinar?
*
MOC marketing emails
MOC website
MOC Behavioral Health Consultant (BHC)
Provider organization
Community Newsletter
Other:
8. If you answered "Provider Organization" above, please specify which.
Your answer
9. If you answered "Community Newsletter" above, please specify which.
Your answer
10. Do you have any questions for the presenter?
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of University of Michigan.
Report Abuse
Forms
