2017 Houston Healthcare Preparedness Summit Registration
Thank you for your interest in this event. Please fill out only one form per person. If you need to register additional people, there will be an option to submit another registration after you complete this form.
Agency Physical Address
Office/Facility Phone Number
Your Mobile Phone Number (In the event a cancellation or other issue arises during the event)
Home Health Agency
Average Daily Facility Census (Number of people in your facility on a daily basis)
Our facility does not provide in-patient/residential services
Does your facility have an all-hazards emergency plan?
What questions do you have going into the Summit that you'd like answered?
Never submit passwords through Google Forms.
This form was created inside of City of Houston Office of Emergency Management.
Terms of Service