Survey - CBCC Program Inquiry Form - National Eating Disorders Association

1.

Basic information:

*

Name:

First Required	Last Required	Professional Suffix

*

Email: Required

*

Street 1: Required

Street 2:

*

City/State/ZIP:

City Required	State Required	ZIP Required

Country:

Phone Number:

*

Occupation: Required

Yes, I would like to receive e-mail from National Eating Disorders Association

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*2.

Question - Required - What is your racial and/or ethnic identity?

*3.

Question - Required - What is your gender identity?

*4.

Question - Required - Which of the following populations describe you? Check all that apply.
Please make at least 1 selection from the choices below.

	Parent
	Personally Affected
	Friend or Family
	Student
	Educator
	Eating Disorders Professional
	None of the above
	Prefer not to answer

5.

Question - Not Required - If you identified yourself as personally affected, are you in strong recovery?

*6.

Question - Required - Are you a parent or caregiver?

7.

Question - Not Required - If the current workshop dates and times do not work for you, please tell us generally what day of the week and time (including time zone) would work better.

8.

Question - Not Required - If requesting to be added to the waitlist, which workshop dates are you interested in?
Please make between 1 and 3 selections from the choices below.

	August 11th & August 25th, 7-9 pm ET
	September 10th & September 24th, 7-9 pm ET. *This session is reserved for parents or caregivers who are in recovery from an eating disorder.
	October 7th and October 21st, 10 pm-12 am ET (7-9 pm PT)