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Community Health Worker - Interest Form
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Email
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Full Name
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Email Address
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Phone Number
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Name of Shop
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Shop Location
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How did you first hear about us?
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Search Engine (Google, Bing, etc.)
Social Media (LinkedIn, X, Facebook, etc.)
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Industry Event/Conference
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On a scale of 1 to 7, how interested are you in getting trained as a community health worker?
Minimally Interested
1
2
3
4
5
6
7
Highly Interested
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If you are interested in a demo, what is the best time frame for us to reach out?
Morning (9am - 12pm)
Afternoon (12pm - 4pm)
Flexible - Any Time
Monday - Wednesday
Thursday - Friday
Morning (9am - 12pm)
Afternoon (12pm - 4pm)
Flexible - Any Time
Monday - Wednesday
Thursday - Friday
Please share any specific questions or additional comments you have:
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