Living Well With Serious Illness Events
Thank you for your interest in learning more about GOCCNJ's Living Well With Serious Illness events. By connecting a trained Ambassador to your community through these events, people will learn about how to access resources to live well at home. Once you complete the form, our team will be in contact to connect you with a local Ambassador to get an event scheduled at your organization. Thank you for your interest!
Sign in to Google to save your progress. Learn more
Please enter your name:
Organization name:
Email: 
Address: 
Phone number:
County/Counties Served:
Share what communities are served at your organization:
If your organization is culturally-specific, please indicate communities served. 
The presentation delivered by Ambassadors typically lasts between 30-45 minutes depending on the audience and other factors, such as being part of an agenda for a pre-planned meeting or event. Please share dates that you are interested in having an event scheduled. 

Your preferred date is: 
MM
/
DD
/
YYYY
What time? 
Time
:
What is another date that would work for you? 
MM
/
DD
/
YYYY
What time?
Time
:
If you have any other information you would like to share about dates for an event or any other questions, please let us know. 
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Goals of Care.

Does this form look suspicious? Report

Google Forms