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MOSAIC Film Survey: Please complete to receive link!
Thank you for your interests in WMHEN's film MOSAIC! If you'd like to receive a link to the film, please fill out this form.
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Email
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Your email
Name
*
Your answer
Your organization (optional)
Your answer
City/town
Your answer
Would you like to be added to the Western Mass Health Equity Network's email list?
*
Yes
No
Other:
Are you planning to show the film to a group you are involved with?
*
Yes
No
If yes above, what group?
Your answer
Would you like the discussion questions we have developed?
Yes
No
Clear selection
I agree to not share this film, except to the indicated audience
*
Yes
No
I will not post this film on social media.
I agree.
No, I don't agree.
Clear selection
Any other feedback/questions/concerns?
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