Tele Town Hall Enrollment Form

Tele Town Hall Enrollment Form
Tele Town Hall event will happen on April 30, 2021. During this event, you can call us at (123)-456-7890 while watching the live stream at https://www.organization.com/live-stream.php
We'll be discussing the following topics:
- How COVID-19 pandemic changes the health care system?
- How this pandemic changes the educational system?
- Practicing self-discipline and self-control
- Managing mental and emotional well-being during the pandemic
Speakers:
John Smith, M.D.
Rob Hunter, Ph.D.
Jane Doe, M.D
If you want to join, please fill out the form below.
Name
First NameLast Name
Age
Gender
MaleFemale
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Position/Title
Company Name
Is there a specific topic that you want to discuss?
Do you have question that is related to the topic above?
YesNo
If yes, then please post your questions here:
Would you like to receive email notifications coming from our group about our next tele town hall meetings?
YesNo
Should be Empty: