South Jersey MCH Resource Directory Questionnaire

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* 1. Full Name, including credentials (ex: Jane Doe RN, MSN, IBCLC):

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* 2. Contact Address:

Name and/or Agency:

Street:

City:

State:

Zip Code:

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* 3. Phone Number:

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* 4. Email Address:

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* 5. Additional information about credentials and/or qualifications:

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* 6. List your area(s) of Subject Matter Expertise you are willing to be contacted about:

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* 7. Title(s) of Possible Presentation(s):

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* 8. Check the audience(s) you would be willing to present to:

Physicians

Nurses

Social Workers

Patients/Families

Community organizations

Students

Other (please specify)

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* 9. Do you require an honorarium?

Yes

Other (please explain)

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* 10. Please tell us what you're available for:

Presentations

Trainings

Referrals

Consultation

Other (please specify)

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* 11. Please check the counties you would be willing to travel to:

Atlantic

Burlington

Camden

Cape May

Cumberland

Gloucester

Salem

All of South Jersey