June 2017 Meeting

Registration

Instructions: Please complete the following form to register for the Chronic Disease Prevention and Health Promotion Collaborative meeting. The meeting that will be held on Thursday, June 15, 2017 from 9 am - 12 pm at The Place at Innsbrook (4036-C Cox Road, Glen Allen ,Virginia 23060). Water, coffee and tea will be provided.

Registration closes on June 8, 2017.

Prefix: *This question is required.

First Name: *This question is required.

Last Name: *This question is required.

Are you representing an organization or attending as an individual? *This question is required.

Organization Name: *This question is required.

1. Are you a VDH employee?

Title:

Phone: *This question is required.

Email: *This question is required.

Will you need any special accommodations? If yes, please explain.