Membership Registration for AZ Health Professionals for Climate Action (AZHPCA)
Thank you for your interest in collaborating with the Arizona Health Professionals for Climate Action (AZHPCA). We need your help to engage Arizona health professionals to advocate for climate change solutions in order to support a transition to a healthy, equitable, and sustainable future. Please tell us a little bit about yourself and any specific interests you have.
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Name: *
Any healthcare/public health credentials (MD, RN, DO, NP, MPH, N/A): *
Email: *
Phone number:
Street address:
City/Town of residence: *
State of residence: *
Zip code of residence: *
Healthcare/health affiliation/organization: *
Please describe your role in healthcare:
What made you interested in joining this group?
Do you have specific skills that you think could be useful to the work we are doing?
Are you interested in leading or participating on a virtual workgroup? [We'll start with one that has greatest interest and add additional as we have leads/volunteers] *
Required
Are you interested in leading one of the workgroups? *
Other options for getting involved: *
Required
Anything else you'd like us to know?
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