Conference Participant
Registration Information Form

2nd Year SSU Conference on
Addressing the Health Care Crisis in Sonoma County: What We Can Do Locally
April 23 & 24, 2004

Name: _____________________________________________________________________

Address: ___________________________________________________________________

City: ___________________________________ ST: _____ Zip: _______________________

E-Mail: _____________________________________________________________________

Phone (work): _______________________________ (home): _________________________

(Optional) Which of the following Sonoma County stakeholder categories do you most identify with? (place an X before each that applies to you)

1. _____ Community Foundation and funding partners
2. _____ Consumers/public
3. _____ Health plans ansd systems
4. _____ Hospitals
5. _____ Labor unions
6. _____ Large businesses or coporations
7. _____ Local multi-sector health alliances (such as the Sonoma Health Alliance)
8. _____ Media
9. _____ Non-profits
10. _____ Small businesses
11. _____ Professional providers of health services and their associations
12. _____ Public jurisdictions and governments
13. _____ Public and private learning institutions
14. _____ Risk-sharing groups/insurance brokers
15. _____ Health care consultants
16. _____ Legal advisors
17. _____ Actuarial and underwriting resources
18. _____ Uninsureds and their associations
19. _____ None of the above (indicate yours) _______________________________________

Any comments or special areas of interest in health care (use as much space as you wish)

Please send your completed form to Skip Robinson, either by e-mail (skip.robinson@sonoma.edu) or by mail to:

Skip Robinson, PhD
Psychology Department
Sonoma State University
1801 E. Cotati Ave.
Rohnert Park, CA 94928-3609