CCACC Health Workshop Sign-Up Form
CCACC Health Center will provide disease self management workshops to improve the quality of life for patients with diabetes, chronic pain, or family with dementia. Caregivers or families are also welcome to join the workshop to learn self-management strategies.  

All workshop are free to participants. Participants are encouraged to complete the pre and post forms to help us improve our services. Please select the workshops which you are interested in, and we will contact you to confirm participation.
To learn more, please visit  https://www.ccacchealth.org/ or call 240-393-5950 or mail to panasianclinic@ccacc-dc.org 
Sign in to Google to save your progress. Learn more
I am interested in joining the workshop(s): 我想參加的課程為: *
Required
First Name 名字 *
Last Name 姓氏 *
Sex 性別 *
Date of Birth 生日 *
MM
/
DD
/
YYYY
Phone Number 電話 *
Email 聯絡電郵 *
Address 地址 *
Home Zip Code 家庭邮政编码 *
What health insurance do you have? Please check all that apply: 請問您的醫療保險種類為 *
Required
Race/Ethnicity  種族/族裔 *
Asian Race/ethnicity subgroups 亞裔族群
 *

I have used resources or services that I previously did not use.

我使用了我之前未使用過的服務或資源

 *
Thank you for filling out this form. Our staff will contact you with details for this workshop. 謝謝您填寫。我們的同事會與你聯絡關於參加講座的細節。
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Chinese Culture and Community Service Center, Inc.. Report Abuse
Google Forms