2024 CDC DNPAO National Training Registration Form
May 6–9, 2024 • Atlanta, GA • The Westin Peachtree Plaza

1. Registrant Information

First Name*

Last Name*

Organization*

Title*

Program Role*

State*

Office Phone*

Cell Phone*
This number will be used during the in-person meeting for communication, networking, evaluation, etc.

Email*

Preferred First Name on Badge*

First Name*

Last Name*

Relationship*

Cell Phone*


	State Physical Activity and Nutrition (SPAN) Recipient
	High Obesity Program (HOP) Recipient
	Racial and Ethnic Approaches to Community Health (REACH) Recipient
	State Ambassador
	Federal/CDC Staff
	Presenter/Facilitator/Technical Assistance Provider
	Other

Community Design for Physical Activity

Fruit and Vegetable Programs and Food Service Guidelines

Please select your preferred topic.*
	I am most interested in training on Fruit and Vegetable Programs.
	I am most interested in training on Food Service Guidelines.
	I have equal training needs in both topics.

Breastfeeding

Early Care and Education


	Evaluation
	Communication


	Family Healthy Weight Programs
	Tobacco
	Adult Vaccinations
	I will stay through Thursday morning to participate in structured networking and technical assistance consulting.
	I will not attend Thursday.

Arrival Date*

Departure Date*