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STRENGTHENING SOCIAL CONNECTIONS AND PUBLIC HEALTH IN MICHIGAN
MPHA 2021 Summit Registration Form
Date: June 23rd, 2021
Time: 12–3 pm
Virtual Event via Zoom
Contacts: Apryl Brown at (313) 303-1957 or Lisa Danto at
MiPHA.operations@gmail.com
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Email
*
Your email
Michigan Public Health Association (MPHA)
First Name
*
Your answer
Middle Name
(Optional):
Your answer
Last Name
*
Your answer
Job Title and/or Credentials
*
Including: Retired, Students, Volunteers, and/or Professionals
Your answer
Email Address
*
Your answer
Email Address Type
*
Personal
Business
School
Phone Number
(Including Area Code)
Your answer
Phone Number Type
Check all that apply:
Mobile / Text
Landline
Personal
Business
Organization, Employer, or School
*
Your answer
Mailing Address
As Applicable: Building Name, Street Number and Name, PO Box, City, State/Province, Country, & Zip Code:
Your answer
Mailing Address Type
Personal
Business
Temporary
Permanent
Prefer Not To Answer
Are you a current member of MPHA?
*
Yes
No
No, but I am interested in becoming a member of MPHA
Required
Are you a guest member of an APHA State Affiliate organization?
Yes (please answer next question)
No
Identify the APHA State Affiliate organization:
(if answered YES to the previous question)
Your answer
A copy of your responses will be emailed to the address you provided.
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