Health Equity Town Hall Registration
Health Equity Town Hall Registration
Name
Name
*
First
Last
Email
*
Phone
Phone
-
###
-
###
####
In what city do you reside?
*
What is your age group?
*
What is your age group?
Under 18
18–24
25–34
35–44
45–54
55–64
65+
What topics ate you most interested in discussing at the Health Equity Town Hall?
*
What is your biggest health concern for your community right now?
*
Have you experienced barriers in accessing healthcare?
*
Have you experienced barriers in accessing healthcare?
Yes
No
Prefer not to say
If yes, what barriers have you experienced? Check all that apply.
*
If yes, what barriers have you experienced? Check all that apply.
Cost
Transportation
Lack of insurance
Lack of nearby providers
Long wait times
Language barriers
Distrust of healthcare system
Difficulty getting appointments
How did you hear about this event?
*
How did you hear about this event?
Social Media
Church/Faith Organization
Delta Sigma Theta Sorority, Inc.
Friend/Family
Community Organization
School
Email/Newsletter
Would you like to receive information about future community health events and advocacy opportunities?
*
Would you like to receive information about future community health events and advocacy opportunities?
Yes
No
Do you require any accommodations to participate? (Check all that apply)
*
Do you require any accommodations to participate? (Check all that apply)
Mobility accommodations
ASL interpretation
Language interpretation
Dietary accommodations
None
What is your role in the community?
Submit