ORCHID Registration
The Institute for Successful Leadership thanks you for your interest!! Please complete the information below and look for the log-in information!!
* Required
Email address
*
Your email
Last four digits of your cell number
*
Your answer
Zip Code
*
Your answer
Gender
*
Female
Male
Prefer not to say
Required
What is your primary language?
*
English
Haitian Creole
Spanish
Portugese
American Sign Language
Other:
Required
What is your racial background?
*
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Other:
Required
What is your ethnic background?
*
Hispanic/Latinx
Non-Hispanic/Latinx
Other:
Required
What is your age range?
*
21-30
31-40
41-50
51-60
61-65
66 or better
Required
Do you:
*
Yes
No
I don't know
Smoke Cigarettes, Cigars or E-Cigarettes
Live with someone who smokes
Live with high levels of stress
Believe you live a healthy life
Yes
No
I don't know
Smoke Cigarettes, Cigars or E-Cigarettes
Live with someone who smokes
Live with high levels of stress
Believe you live a healthy life
Thank you!!!
On behalf of the Institute for Successful Leadership and the Florida Department of Health, Office of Minority Health & Health Equity, thank you for your participation. We look forward to helping you step into 2021 with a healthy heart!!! THANK YOU!!!
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