REACH Partnership Interest Form

Honorific (Rev., Dr., Mr., Mrs., as applicable)

First Name

Last Name

Degrees (MDiv, etc...if applicable)

Name of Faith based Institution or Organization

Title (if Applicable)

Address Line 1 (street address)

Address Line 2 (suite, floor, room, unit)

Zip Code

Area or Neighborhood Where You're Located or Where Most Congregants Live:

Institution or Organization's Phone Number

Your Position/Title With the Faith-Based Organization

Your Preferred Contact Phone Number (optional, indicate cell)

Your Preferred Email Address

Do you have a health/wellness ministry or program? Do you have a health/wellness ministry or program? Yes No

Contact information (phone email) for head ot this ministry (if different from you):

Social Media posts - notification Social Media posts - notification I'm interested in receiving a culturally-relevant social media post-of-the-week (via email) to share via my organization's social media.

What health disparities or chronic health issues are most relevant for your congregants and neighbors? (select top 3) What health disparities or chronic health issues are most relevant for your congregants and neighbors? (select top 3) Hypertension/high blood pressure Diabetes Asthma COVID-19 Seasonal flu Affordable health insurance/coverage Obesity Mental health/wellness Substance misuse disorders Physical activitiy and nutrition Finding a family/primary doctor Other

Other (health disparity or issue)

What topics or issues would you like information about from the County Health Department as part of its REACH activities?