Event Registration: Emerging Collaborative Care Models for Dementia in the Primary Care Setting On-demand Registration is required to obtain link. Fields marked with an * are required First Name * Last Name * Email * Phone * Divider Age * None 19 and under 20-29 years 30-39 years 40-49 years 50-59 years 60 and over Gender * Male Female Prefer not to answer Race * American Indian / Alaskan Native Asian/Asian American Hispanic/Latinx Native Hawaiian/Pacific Islander Black/African American Non-Hispanic/White Other If Other, Specify Race Ethnicity * Hispanic/Latino Asian/Asian American Non-Hispanic/Non-Latino Other If Other, Specify Ethnicity Did you come from a disadvantaged background? (e.g. receive public assistance, food stamps, housing assistance) * Yes No Did you live in a rural area during the majority of your childhood? * Yes No What is your primary role? * Health Professional / Provider University Faculty Resident Fellow Student Other If Other, Specify Primary Role What is your current employment status? * Full-Time Part-Time On Leave Student Retired Name of place of employment * Cleveland Clinic Lou Ruvo Center for Brain Health University of Nevada Las Vegas Practice Plan Willima Bee Ririe Clinic Nevada Adult Day Healthcare Center University of Nevada, Las Vegas Mission Pines Nursing & Rehab Volunteers in Medicine of Southern Nevada Other If Other, Specify place of employment What is your educational degree or credentials? * Bachelors Masters PhD PA NP MD/DO RN PharmD MSW/LCSW Physical Therapy Occupational Therapy DDS/DMD Associate CHW Other If Other, Specify Education Please indicate your primary discipline. (e.g. family practice, specialty, sub-specialty, psychology, etc.) * Employer Zip Code * Have you ever served in the armed forces? * Yes No Recaptcha Divider HTML Please contact us for any further details If you are a human seeing this field, please leave it empty.
