Healthcare Committee
Thank you for your interest in joining the Healthcare Committee. The goal of the Committee is to raise awareness and provide education for healthcare providers in order to ensure that human trafficking survivors are recognized, referred and receive appropriate treatment. The Healthcare Committee typically meets bi-monthly via conference call. In order to best serve your interest, please complete the following survey. Please allow 2 to 3 days for a response. Thank you for your interest.

Please complete the form to make your application.

Email address *
Full Name *
Your answer
Cell Phone *
Your answer
Describe your educational background. If you are a student, please identify your grade level and current school or university. *
Your answer
State your professional title. *
Your answer
State your organization of employment. *
Your answer
Have you been/are you currently involved with anti-human trafficking efforts? If so, briefly explain. *
Your answer
Identify areas of the Healthcare Committee in which you are most interested. *
Required
Select your desired level of involvement. I am available: *
What do you hope to achieve from serving on the healthcare committee? *
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service