Application: CA4Health Building Equity Into Everyday Practice Workshops
Event: November 19, 2019 from 9:00am-3:30pm
Address: Chico Masonic Family Center, Chico CA
Questions? Email our team at
ca4health@phi.org
* Required
As you complete this application, please note:
- Applications will be reviewed and accepted on a rolling basis and space is limited, so we encourage you to apply early. The final deadline for applications will be November 8th.
- All are welcome to apply! Priority will be given to CA4Health members, teams of 2+, and those presenting a concrete project or idea to workshop.
- If you have colleagues that want to participate in both workshop areas, you will have to submit separate applications for each team and/or workshop area.
Primary contact NAME for your application
*
Your answer
Primary contact EMAIL for your application
*
Your answer
Organization or Initiative your team will be representing
*
Your answer
Which workshop would you like to attend? (Note: they will be happening simultaneously, so only pick one)
*
Alliance Building for Health Justice and Equity facilitated by Xavier Morales, Ph.D., MRP, Executive Director with Praxis Project. Work on strategies for building and creating authentic partnerships to advance health justice and racial equity.
Storytelling for Change facilitated by Rachel Poulain, MPH, Narrative Change Strategist at The California Endowment. Work on creating narratives that make a stronger case about and for equity and social justice.
Briefly describe the concrete project or idea you would like to workshop in the session selected?
*
Your answer
What are the names and roles of the people attending as part of your team?
*
Your answer
In addition to the specific workshop areas, there will be time for more general, small group discussions. To inform how this part of the agenda is structured, please let us know up to 3 topics or questions you'd like to discuss with your peers.
*
Your answer
A limited number of team travel stipends up to $200 are available to teams with CA4Health members. Are you/any members of your team CA4Health member(s)?
*
Yes
No
If you ARE a CA4Health member, will you require the team travel stipend ($200 maximum) to support costs to attend?
Yes
No
If you are requesting a team travel stipend, please indicate how much you anticipate needing (not to exceed $200 for your entire team).
Your answer
If you or a member of your team will have any needs for accommodation please describe them here:
Your answer
A light breakfast and lunch will be provided. Do you have any dietary needs?
*
None
Vegetarian
Vegan
Gluten-free
Other:
Required
Additional comments and/or questions?
Your answer
Brought to you by:
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
