Lung Health Navigator Education Enrollment Form

Lung Health Navigator Education Enrollment Form

1-866-252-2959

PARTICIPANT INFORMATION

First Name

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Last Name

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Mailing address

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City

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State

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Zip Code

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Email address

This field is required in correct email format.

Daytime Phone Number

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Which education series would you like to enroll in?

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Best Time To Call (Weekdays)?

10am-Noon

Noon-2pm

2pm-4pm

4pm-5pm

5pm-7pm

Anytime

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PARTICIPANT CONSENT

I authorize my agency to release the information on this enrollment form to the American Lung Association (ALA) for purposes of my participation in the Lung Health Navigator education program and also authorize the ALA and it representatives to contact me at the phone number I have listed above. I give the ALA and the referring agency permission to discuss my use of service. If consent is given over the phone by the participant, please note on the signature line.

AGENCY STAFF: Please select the method in which participant consent was obtained

Obtained in person

Obtained on phone

AGENCY INFORMATION

Agency Name (please select from dropdown list):

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Today's Date

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1-866-252-2959