STRENGTHENING SOCIAL CONNECTIONS AND PUBLIC HEALTH IN MICHIGAN
MPHA 2021 Summit Registration Form
Date: June 23rd, 2021
Time: 12–3 pm
Virtual Event via Zoom
Contacts: Apryl Brown at (313) 303-1957 or Lisa Danto at
Sign in to Google
to save your progress.
Michigan Public Health Association (MPHA)
Job Title and/or Credentials
Including: Retired, Students, Volunteers, and/or Professionals
Email Address Type
(Including Area Code)
Phone Number Type
Check all that apply:
Mobile / Text
Organization, Employer, or School
As Applicable: Building Name, Street Number and Name, PO Box, City, State/Province, Country, & Zip Code:
Mailing Address Type
Prefer Not To Answer
Are you a current member of MPHA?
No, but I am interested in becoming a member of MPHA
Are you a guest member of an APHA State Affiliate organization?
Yes (please answer next question)
Identify the APHA State Affiliate organization:
(if answered YES to the previous question)
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service