Chronic Pain Enrollment Survey- September 2022

What is your name? *This question is required.

Last
First

Email Address *This question is required. This question requires a valid email address.

Phone Number *This question is required.

Home Address (for mailing)

Address
City
Zipcode

3. I agree, that in accordance to the Sanford Center for Aging's Chronic Pain Self-Management Program, that I join this class knowing that participation requires full audio (microphone/speaker) and video (webcam/camera) capabilities in order to maintain my place within the program. Any technology issues will be attempted to be resolved with or without Sanford Center for Aging staff. Inability to meet audio and visual standards will result in my withdrawal from the program in accordance to the privacy and confidentiality standards held by this program.

Please type your Full Name in Acknowledgement of these Standards. *This question is required.

Chronic Pain Enrollment Survey- September 2022

Chronic Pain Self Management Client Enrollment