REACH Registration Form

Thank you for your interest in the REACH Pediatric Palliative Care and Hospice ECHO™ Program. Register below to attend monthly REACH sessions and receive information on program updates.
Email address (use email address that is already linked to your Zoom account, if you have one)*
example@example.com
Name*

First NameLast Name
Your hospice organization:*
State in which you practice*

Tennessee*Other
*Hospice nurses practicing in the state of Tennessee are eligible to receive CEUs for participation. Additional details to follow after you register.
How old are you?*

20-29 years30-39 years40-49 years50-59 years60 years or olderPrefer not to respond
Which group best describes your racial background?*

White/CaucasianBlack/African AmericanAsian/Pacific IslanderArabic/Middle EasternNative American Indian/Alaskan NativePrefer not to respondOther (please describe)
Do you consider yourself Hispanic/Latino*

YesNoPrefer not to respond
What is your gender identity*

MaleFemaleTransgender maleTransgender femalePrefer not to respondDifferent Identity (please describe)
What is your primary profession?*

Hospice nurseHospice AdministratorHospice physicianHospice advanced practice providerHospice chaplainHospice social workerChild life specialistOther (please describe)
How did you hear about the REACH Pediatric Palliative Care and Hospice ECHOProgram? (Select all that apply)*

ColleagueWebsiteConferencePresentationAnother ECHO programDon't recallOther (please describe)
Why are you interested in participating in this program? (Select all that apply)*

To increase knowledge about pediatric palliative and hospice careTo become more comfortable managing pediatric palliative and hospice patientsTo network with colleaguesTo gain access to experts in pediatric palliative and hospice careOther (please describe)
By completing this registration form, you consent to the collection, use and disclosure of your personal information and responses for these purposes: registration, program planning and reporting, program evaluation/research in the future, and updates on new initiatives.
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