Skip to content

Winter 2021 Geriatric Healthcare Series: Profile Form

Please register for the Geriatric Healthcare Series by filling out this form. You will receive a confirmation email with the Zoom information and you will be added to an email list and receive reminders before each lecture. 

Should you have any problems filling out this form, please email nwgwec@uw.edu.
1.What's your name (first and last)?(Required.)
2.Your credentials / degree(s) (eg: RN, DO, ARNP)?(Required.)
3.Name of your current employer:(Required.)
4.What's your current health profession? (based on funding agency categories, please choose the one that best fits your profession)(Required.)
5.What state do you live in?(Required.)
6.What city do you live in?(Required.)
7.What's your email address? Enter only 1 email address. Please check for typos, if it's incorrect, you will not receive the confirmation email.(Required.)
8.Please select if any of the following is true (mark all that apply):(Required.)
9.Do you currently work in a (mark all that apply):(Required.)
10.Do you intend to obtain Continuing Education for this course?(Required.)