Register to be a downlink site

9th Annual SPHRIMH	The University of North Carolina at Chapel Hill Program for Ethnicity, Culture, and Health Outcomes (ECHO)	10th Annual SPHRIMH

	Your guide to minority health-related activities at UNC-CH and elsewhere

Step 3: Registration form

Organization (* = required field)

*Organization name	Organization type

Web site URL for your organization

Does your organization's primary mission specifically involve
African Americans?	American Indians/Native Americans?
Asian/Pacific Islander Americans?	Hispanic/Latino Americans?

Postal address				City

State (if USA)	State or province (if not USA)	*Postal code (all parts)
		-

Country
USA	Canada	Mexico	Other	If Other, Please Specify

Viewing Location (where the program will actually be viewed at your site - if different from above)

Name of facility	Number and/or name of room/auditorium

Street address of viewing location (if different from Organization address)

Street address	City

State	Postal code (all parts)
	-

How many people can the room accomodate?
Will the public be welcome to attend? Yes No	Are you taping only? Yes No
Will there be a registration fee? Yes No amount, if known:
Does your facility have the capability of disseminating the videocast to other locations and would you like to do so? Yes No

Site Facilitator (the person who is responsible for coordinating this event at your site - this person's name and contact information will be placed on our web site unless you request otherwise):

*First name	Middle name	*Last name

*E-mail
Would you like to receive announcements (maximum 12 / year) about minority health / public health events available via satellite or Internet? Yes No

*Telephone	Fax	Website

How did you first learn about the conference?

Technical Coordinator ( the additional person to whom the satellite coordinates should be sent):

    First name    Middle name    Last name

E-mail

   Would you like to receive announcements (maximum 12 / year) about minority health / public health events available via satellite or Internet?     Yes No

   Telephone    Fax    Website

    Comments

Please note:
As a grant-supported activity our ability to offer these programs depends upon being able to document their value. Please help us by providing an accurate count of the number of broadcast participants at your site and completing the online site facilitator evaluation.

Minority Health Project| Department of Epidemiology
UNC Gillings School of Global Public Health
2104D McGavran-Greenberg, CB#7435 | Chapel Hill, NC 27599-7435
Phone 919-966-7436 | Fax 919-966-2089| E-mail Minority_Health@unc.edu

Last updated: 04/14/2007 by Vic