Updated Video Conference Reservation Form

* Date of Conference:

* Start Time:


* End Time:


Conference Subject:

Conference Leader:

Presenting with a computer?

Yes No

Will you be using a telehealth cart?
If Yes, add to "Additional Comments" section below.

Yes No

Contact for Meeting:

Contact Phone Number:

* Host Site:


Approximate Number of Participants at Host Site:


Conference Participants:
(Please select all that you will invite.)

District Health Officers - Administrators  
District Assistant Administrators  
District Administrative Support Staff  
District Business Managers  
District Care Coordinators: Directors - Managers  
District Clerical Directors  
District Environmental Directors  
District EP Coordinators  
District EP Environmentalist  
District Home Care Directors  
District HIV Program Coordinators  
District Immunization Program Managers  
District Nursing Directors  
District Nutrition Coordinators  
District Social Work Directors  
District Surveillance Nurses  
District Tobacco Prevention Coordinators  
AllKids Regional Coordinators  
Breast and Cervical Cancer Coordinators  
EMS Regional Directors  
Healthy Child Care Coordinators  
Perinatal Coordinators  
Vital Records Registrar  
Other  

Participating Sites:
(Please select no more than 11 sites.)

Central Office 866  
Central Office 944  
Central Office 982  
Central Office 1066  
Central Office 1142  
Central Office 1318  
Central Office 1366  
Central Office 1554  
CLAB - Prattville  
Northern - Colbert  
Northern - Morgan  
West Central - Tuscaloosa  
Northeastern - Etowah  
Northeastern - Calhoun  
Southwestern - Marengo  
Southwestern - Monroe  
Jefferson County  
East Central - Montgomery  
Southeastern - Coffee  
Southeastern - Houston  
Madison County  
Medicaid Agency 3012  
Chilton County  
Lee County  
Tuscaloosa Community Room  
Walker County  

Additional Comments:

Your completed Video Conference Reservation Form will be emailed to Health Media and Communications. You will receive a confirmation email and they will set-up the conference for you.

If you have any questions, contact Sandra Blakely at
(334)206-5635 or (334)206-5618. Thank you.