York County Forum Registration The Maine Shared Community Health Needs Assessment is a dynamic public private partnership that compiles data, engages and activates our community to discuss the data, and build plans to address our most pressing health needs. We invite you to join us in this conversation so that together, we can become the healthiest state in the nation. OK Question Title * 1. Please tell us about yourself. First Name Last Name Organization Job Title OK Question Title * 2. Please provide contact information (Optional). email address phone OK Question Title * 3. We hope you can attend a York County community forum. Check all that apply Yes, I am attending September 27th 9-11am York Community College, Wells Yes, I am attending September 27th 3-5pm Saco City Hall, Saco No, I can not attend. If you wish to receive future mailings, please include your email address in #2 above OK Question Title * 4. Which community sector do you primarily represent? Education Healthcare Faith-based Government Other Non-Profit Private Sector/Business Public Health Social Services Tribal Community Member Other (please specify) OK Question Title * 5. Within the community sector you identified, what is your primary role? Clinical provider Community member Consumer (ie: client, patient) Educator Leadership/Management Professional/Non-clinical Staffer Volunteer Other (please specify) OK Question Title * 6. I understand that my name, photograph, voice or likeness may be used for all promotional purposes related only to the Community Engagement Forum by any of the Partnering Event Organizers and their sponsors, beneficiaries, licensees, affiliates and employees. I consent to and authorize, in advance, such use and waive all rights of privacy I have in connection therewith. I also understand that I will not be entitled to any payment or other form of compensation from any use thereof. I understand and agree to the above statement I do not wish to have any images or likeness of myself published in any reports For those who do not wish to have their image or likeness published in any reports, please add your name below. We will make accommodations. OK With support from the Maine Shared CHNA collaboration partners: Central Maine Healthcare, EMHS, (EMHS to become Northern Light Health October 1), MaineGeneral Health, MaineHealth, and the Maine Center for Disease Control and Prevention. OK DONE