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About
Board of Directors
Strategic Plan
Resources
WV AMP
News
Events
Get Involved
Contact
Donate
Become a Member
Conference
WV Health Jobs
Free Conference Registration
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Mobile Phone
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Your mobile phone number will not be shared. It is used for the conference application verification only.
Company/Employer Name
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Work Phone
Work/Practice Location(s) Address
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Address Line 1
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City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Work/Practice Location(s) County
*
Number of years/months worked at this site:
Do you currently serve as a preceptor for students?
Choose One
Yes
No
Name of health professional school attended, if applicable
Year of Graduation
As a student, did you participate in a rural or community rotation?
Choose One
Yes
No
Do you have any dietary restrictions?
*
Yes
No
If yes, please list dietary restrictions.
Are you currently a student?
*
Yes
No
Do you want your contact information to be available to sponsors?
*
Yes
No
Are you interested in claiming CEU credit?
*
Yes
No
WVRHA has applied for CEU credits for the fields listed below. Please check the box beside your field.
Physician
Physician Assistant
Nurse Practitioner
Nurse
Pharmacy
Psychology
Social Work
Health Profession/Worker Discipline (if your chosen professions ask to specify specialty/discipline, please do so in the following question)
Advanced Practice Registered Nurse (specify)
Allied Health
Caregiver
Case Manager
Chiropractor
Clinical Nurse Specialist (specify)
Community Health Worker
Counseling
Dental Assistant
Dental Hygienist
Dentist
Dentist, Oral Surgery
Dentist, Pediatric Dentistry
Dentist, Endodontics
Dentist, Orthodontics
Dentist, Prosthodontics
Dentist, Pathology
Dentist, Radiology
Health Education
Dietitian/Nutritionist
First Responder
Health Information Technology/Health Informatics
Home Health Aide
Marriage and Family Therapy
Medical Assistant
Medical Interpreter
Nurses (Licensed/Practical)
Nurse (Registered)
Nursing, Other (please specify)
Nutritionist
Occupational Therapist
Optometrists
Pastoral/Spiritual Care
Pharmacist
Physical Therapist
Physical Therapist Assistant
Physician (please add specialty)
Physician Assistant
Podiatrist
Psychologist, Clinical
Psychologist (specify)
Public Health - Biostatistician
Public Health - Disease Prevention & Health Promotion
Public Health - Environmental Health
Public Health - Epidemiology
Public Health - Health Policy & Management
Public Health - Infectious Disease Control
Public Health - Injury Prevention
Public Health - Social & Behavioral Sciences
Recreational Therapy
Respiratory Therapist
Retired and/or Unemployed
Social Work, Clinical
Social Work (specify)
Speech Therapy
Student
Substance Abuse/Addictions Counseling
Veterinarian
Other, not listed (specify below)
Specialty/Discipline (if applicable)
Do you plan to apply this training toward your employment requirements, continuing education credit, certification, or credentialing?
N/A
Yes
No
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