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 MiPHA.operations@gmail.com

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Michigan Public Health Association (MPHA)
First Name *
Middle Name
(Optional):
Last Name *
Job Title and/or Credentials *
Including: Retired, Students, Volunteers, and/or Professionals
Email Address *
Email Address Type *
Phone Number
(Including Area Code)
Phone Number Type
Check all that apply:
Organization, Employer, or School *
Mailing Address
As Applicable: Building Name, Street Number and Name, PO Box, City, State/Province, Country, & Zip Code:
Mailing Address Type
Are you a current member of MPHA? *
Pflichtfrage
Are you a guest member of an APHA State Affiliate organization?
Identify the APHA State Affiliate organization:
(if answered YES to the previous question)
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