Interest form for: 4 Session Learning Series on Diversity, Equity, and Inclusion in Health Care Delivery

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IMPORTANT
Please complete the form below to express your interest in attending the upcoming 4 Session Learning Series.

We will be selecting a representative cohort and will be contacting attendees the first week in May.

This 4 Session Learning Series meets on four session dates. Please plan to attend all four dates: May 20, 4:30 – 6:30 PM, June 10, 4:30 – 6:00 PM, September 23, 4:30 – 6:30 PM, October 14, 4:30 – 6:00 PM.

This is a free program. Credits will be awarded upon completion of all 4 sessions.

NOTE: This form is confidential and will only be shared with the selection committee and will not be disclosed or used for any other purposes.

Deadline for completing this form: Friday April 30, 5:00 pm ET

First Name *

Last Name *

Your Email Address *

Organization where you work *

Address of organization where you work *

Your Phone Number *

Please provide a brief statement on why you would like to attend/participate in this 4 session learning series and how you hope to use the information in your work setting. *

Please provide a brief statement about how you feel your identity impacts your work. *

This 4 Session Learning Series meets on four session dates. Please plan to attend all four dates: May 20, 4:30 – 6:30 PM, June 10, 4:30 – 6:00 PM, September 23, 4:30 – 6:30 PM, October 14, 4:30 – 6:00 PM.

Statement on attendance. *

I understand that there are limited seats available. I will check my calendar and commit to attending all four sessions.

Required

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