Join a Virginia Health Catalyst Statewide Workgroup Please complete this form to join one of Virginia Health Catalyst's statewide workgroups. First Name*Last Name*Email* Phone*Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Age Under 18 18-24 years old 18-24 years old 25-34 years old 35-44 years old 45-54 years old 55-64 years old 65+ years old Gender Female Male Non-binary/third gender Prefer not to say Prefer to self-describe Race and Ethnic Background (select all that apply) Native American Indian or Alaska Native Hispanic or Latino Asian Black or African American Native Hawaiian or Other Pacific Islander White Some other race, ethnicity, or origin Organization*Job Title*Discipline Primary Care Physician or Physician's Assistant Oral Health Provider Prenatal Care Provider Nurse or Nurse Practitioner Community Health Worker Social Worker Public Health Professional Nonprofit Professional Other How did you hear about Catalyst? Friend/Colleague Internet search Organizational newsletter Catalyst newsletter Social media Other How did you hear about Catalyst?Which statewide workgroup would you like to join?* Community Water Fluoridation Rapid Response Team Policy Committee School-based Health Workgroup Early Dental Home Workgroup Why would you like to join the CWF Rapid Response Team?*Discipline*DentistryMaternal HealthGeneral PracticeNursingPediatricsPharmacyDiet/NutritionSocial WorkPopulation HealthHealth Center/Hospital AdminstrationCommunity Health/Social ServicesThis field is hidden when viewing the formAre you interested in serving as faculty for Virginia Health Catalyst trainings, as your schedule allows? Yes No This field is hidden when viewing the formCV/Resume UploadTo be considered for the Clinical Advisory Board please attach your resume or CV. If you would prefer to send your materials by email, please contact bbergland@vahealthcatalyst.org Drop files here or Select files Max. file size: 256 MB. This field is hidden when viewing the formE-SignatureBy checking the box below, I agree that I have read and understand the expectations of Clinical Advisory Board membership, and I believe in Virginia Health Catalyst's Guiding Principles. I agreeWhy are you interested in joining the Virginia Health Catalyst's policy committee?*Representing underserved populations is an explicit and guiding focus for Virginia Health Catalyst. If you have experience or specific interest in serving underserved populations (e.g. racial, ethnic, or linguistic minorities; rural residents; safety net or publically insured Virginians; people with disabilities, etc.), please tell us here.*Would you like to represent yourself as an individual or an organization?* Individual Organization If you selected "Organization," which organization will you represent?E-Signature*By checking the box below I agree that: I have read and understand Virginia Health Catalyst's Guiding Principles. I understand that all the Virginia Health Catalyst policy positions reflect these principles. I agree to use these Guiding Principles to help determine Virginia Health Catalyst's policy positions. I agree to participate in at least 80% of Policy Committee meetings either in person or via webinar. I agreeCAPTCHA
