2026 Native Communities Home Visiting Meeting

Registration Form

2026 Native Communities Home Visiting Meeting

Personal Information

Salutation:

First Name*:

Last Name*:

Suffix:

Badge Name (how you would like your name to appear on your badge)*:

Tribal Affiliation (if applicable):

Tribe/Organization Representing at this Meeting*:

Job Title*:

State/Territory*:

Phone*:

Email*:

Cc email: (for confirmation)

Are you directly associated with a home visiting program serving Native families*?

• Yes

• No

Please select the role most closely describes your work:

• Program Administrator/Director/Lead

• Home Visitor

• Data/evaluation staff

• Federal staff

• State administrator

• Funder

• Model developer

• National TA provider

• Program support staff

• Tribal Leader

• Other:

Emergency Contact

Emergency Contact Name (of someone not traveling with you)*:

Emergency Contact Phone Number*:

Special Requests

ADA Requests (select all that apply):

• Wheelchair accessibility

• Visual impairment

• Hearing impairment

• Accompanied service dog

• Other

Data Privacy Notice

Personal Information

Personal information is being collected by Meeting Management Services & EdgeReg on behalf of THRIVE/James Bell Associates. This information includes attendee name, organization name, address, phone number, email address. This data is required in order to provide and oversee registration services to you. Any additional information requested during the registration process is either required to fulfill the registration services or at the direction of THRIVE. 

Contact Information will be used to email THRIVE event-related information, provide customer service, and create name badges. Attendee information will be stored indefinitely for the purposes of historical reporting only.

For more information on how your data is stored, to make modifications to your personal data, or to have your personal information deleted after the event, please contact the registration manager at [email protected].

Please enter your initials below stating that you have read and understand the above data privacy policies as provided by James Bell Associates and its partners, as it pertains to the 2026 Native Communities Home Visiting Meeting.*

Sharing of Attendee Contact Information

Unless otherwise noted below by selecting the opt out check box, your name, title, grant affiliation/organization, phone number, and email information will be included on the 2026 Native Communities Home Visiting Meeting attendee list. The list will be distributed to all meeting attendees and included in the meeting app.

☐ I opt out of including my name and contact information on the 2026 Native Communities Home Visiting Meeting attendee list.

Photography, Video, and Recording Policy

Attendance at, or participation in, the 2026 Native Communities Home Visiting Meeting and its related events constitutes consent to the use and distribution by the Department of Health and Human Services of the attendee's image or voice for informational, publicity, promotional and/or reporting purposes in print or electronic communications media.

Cancellations or Modifications

Should you need to modify your information or cancel your registration, please email [email protected].

*Required field

PAPERWORK REDUCTION ACT OF 1995 (Public Law 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to register for a meeting. Public reporting burden for this collection of information is estimated to average 5 minutes per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0617 and the expiration date is 9/30/2026. If you have any comments on this collection of information, please contact Anne Bergan, at [email protected].  

 

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NHVM Registration Form