Healthy Beginnings, Workshop Registration

* Indicates required field.

Name*

First

Last

Date

yyyy/mm/dd

Address*

Address 1

Address 2

City

State

Postal Code

Country

Profession/Employment*

Primary phone number*

Additional phone number (optional)

Name of your local church:*

How many adults attend on an average Sabbath?*

Your current church responsibility?

How did you become acquainted with CHIP? Please check all that apply.

Dr. Diehl’s books

3ABN

Camp meeting series

Flyer sent to churches re: this workshop

Attending a Video-CHIP program

Other

If you selected "other" in the previous question, please specify.

What experience have you had in health ministry outreach?*