Form for Learning Series

Interest form for Learning Series on Diversity, Equity, and Inclusion in Health Care Delivery

Location: Online via Zoom

Dates: May 20, 4:30 – 6:30 PM, June 10, 4:30 – 6:00 PM, September 23, 4:30 – 6:30 PM, October 14, 4:30 – 6:00 PM

Please complete the form below to express your interest in the upcoming Learning Series.

Name*
First Last
Email*
Enter Email Confirm Email
The organization of your primarily work.*
Your Title*
Organization Address*
Street Address City State / Province / Region ZIP / Postal Code
Cell Phone Number*
Please provide a brief statement on why you would like to attend/participate in this learning series and how you hope to use the information in your work setting.*
Please provide a brief statement about how you feel your identity impacts your work.*
This learning series will happen in four sessions on four dates. Please check your calendar and acknowledge below that you can commit to attending all four sessions. Please note, there are limited spaces available and attendance is important for the learning.
- Yes, I understand there are four dates and I will attend all four.
- I don't understand.
Thank you for completing the form and expressing your interest in attending this learning series. There are limited spaces available and we will be contacting individuals about the course soon.
- Yes, I understand.
- I don't understand.