AMPHS: NYC Care Workshop Interest Form

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Thank you for your interest in hosting NYC Care Workshop at your site. Please complete the following form to schedule a a workshop with us! The workshop cover topics on access to FREE/LOW-COST medical care through NYC Care, regardless of immigration status, among other healthcare access topics. We provide workshops in English, Spanish, Chinese, and Arabic. Each workshop lasts about an hour. We will do our best to customize the workshop for your members. Additionally, our team is available to share other resources that our organization has to offer by setting up a table at any of your ongoing events.

For questions, please contact Gisel Garcia, Community Health Partner at AMPHS at gisel.garcia@amphsonline.org

Email *

Your Name *

Title *

Organization/School *

Phone Number *

Work Address *

Zip Code *

Contact Person Name (if different than above)

Contact Person Title

Contact Person Phone

Contact Person Email

On which dates or times would you like to hold the workshop? (If you are unsure of the exact dates at this time, please indicate the day or time of the week that is most convenient for your members and we will work with you on confirming a time.) *

If there are time limitations for the workshop, please indicate how much time is available for the session. *

Would you prefer a workshop in-person or virtually? *

In-person

Virtually

Please indicate the format of the workshop (check all that apply): *

Standalone workshop

Held jointly with another meeting or event (e.g. PTA meeting, resource fair, etc.)

Open to the public

Closed workshop

Required

Will the following resources be available for use during the workshop? (check all that apply) *

Online Conferencing Platform (please indicate platform name under "Other")

Projector

Projector Screen or Space (e.g. white wall)

Laptop or computer

Speakers

Translation Headsets

Interpreters (please indicate languages spoken by intepreters under "Other")

None of the above

Required

In which languages would you like the presentation to be conducted? (check all that apply) If there is a majority language spoken, please indicate in the comment box at the end of this form. *

Arabic

Chinese Cantonese

Chinese Mandarin

English

French

Haitian Creole

Spanish

Other:

Required

Any other comments or questions?

Submit

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