subject_line
First Name
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Last Name
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Organization or Association represented
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Title
Address 1
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Address 2
City
*
State
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Postal Code
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Phone
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Email Address
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Contact me via email with information and announcements.
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Yes
No
Current level of participation
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attend meetings regularly
attend meetings inconsistently
attend meetings only when I have something to contribute
attend meetings via conference conference calls
do not attend/receive and read minutes
Anticipated level of participation
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Less participation
More participation
Same as past
Areas of interest in Keiki Injury Prevention Coalition (check as many as needed)
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All areas
Child Passenger Safety
Safe Sleep
Water Safety
Playground Safety
Pedestrian Safety
Anti-bullying
Suicide Prevention
Sports Injury Prevention
Bicycle Safety
Poison Prevention
Epidemiology
Evidence Based interventions
Other Interests
Other Interests
How do you feel Coalition meetings could be improved?
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How do you feel KIPC could promote more interaction and collaboration between coalition members?
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I would like to continue to be a part of the Coalition and receive minutes as well as communications from
KIPC
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Yes
No