Health Action Summit - April 10, 2008

	After you complete this registration form, you will receive a confirmation email that should be printed and mailed to the Jefferson County Department of Health along with a check for $25 to cover a continental breakfast, lunch and program materials. Please fill in this form to register. The red dots indicate required fields.
	Title
	First name
	Last name
	Job Title
	Organization
	StreetAddress (Line 1)
	Street Address (Line 2)
	City
	State
	ZIP Code
	Telephone (xxx-xxx-xxxx)
	Fax (xxx-xxx-xxxx)
	Email
	Area of Expertise
	*Other Area of Expertise
	Please select the concurrent session you are interested in attending - Session A (select one)			Unnatural Causes: Tools for Community Action Revitalizing our Community: One Building at a Time Universal Access to Care: The Conundrum of Expected Benefits Public Policy for Health Equity Orientation to Health Action
	Please select the concurrent session you are interested in attending - Session B (select one)			Solutions to Social and Economic Disparities Planning Smart for the Future Universal Access to Care: The Conundrum of Expected Benefits Creating an Advocacy Agenda
	Persons with disabilities or special needs should send a description of any services needed to Greg Townsend at greg.townsend@jcdh.org or call 205-930-1401.


	Press the button to confirm your registration.