Disability Friendly Provider DFP Workshop Registration Form

Each individual person attending must register.
Thank you so much for your interest in joining disABILITYsa in our efforts to break down the barriers that may inhibit individuals living with various disabilities from seeking care at local pharmacies and clinics. Through our Disability-friendly Provider Workshop, participants can increase their knowledge on how to easily make a healthcare environment more disability-friendly.

Each individual person attending must complete the registration form below. Thank you.

Name*

First NameLast Name

Title*

Position/Credentials*

Please Describe:*

Which session are you registering for?*

October 21st,2023 8:30am - 11:30amNovember 14th,2023 5:00pm - 8:00pmFebruary 25th, 2023 9:00am-12:00pmMarch 23rd, 2023 5:30pm-8:30pmMay 9, 2023 8:00am-11:00amJune 10th,2023 8:30am - 11:30amCANCELED July 11th,2023August 18th,2023 8:00am - 11:00am

Registration for the March 23rd and February 25th sessions is now closed. Please select an alternate date/time. We look forward to having your participation in one of our future workshops. Thank you!

Clinic/Pharmacy Name:*

Total # of Staff at your pharmacy/clinic?*

Physical Pharmacy/Clinic Address*

Street Address

Street Address Line 2

CityState

Zip Code

Email*

example@example.com

Cell Phone Number*

Please enter a valid phone number where you can be reached via text message.

Are you the lead manager/decision maker for your location?*

YesNo

Workshop Registration Summary

RegistrationIndividual Workshop Registration [FREE]

$ Free

3.5 CEUs

$ Free CEU Options

Disability-friendly Starter Kit Product Image

Disability-friendly Starter KitIncludes: Buzzy, DisatrACTION Cards, Shotblocker, Weighted Blanket, Bubble Machine, Noise Cancelling Earmuffs, Dexterity Support Pen Holder, Signature Guide, Magnifying Glass, Fidgets, Communication Boards, Guide Book, Countertop Support Decal, and more in a storage Container.

$325.00

Total

$0.00

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