Participant preregistration form for the 14th Annual Summer Public Health Research Videoconference on Minority Health

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

14th Annual Summer Public Health Research
Institute and Videoconference on Minority Health

Pregistration for the Institute / Videoconference at UNC

Please register here to attend the Videoconference at the UNC
School of Social Work Tate-Turner-Kuralt Auditorium (info)

E-mail address:

Would you like to receive e-mail
announcements?

Yes (maximum 12/year; about minority health / public health events)
No

Name:


First	Middle	Last

Participant code:

(Please choose a 4 digit number, e.g., last 4 digits of home or other phone number.)

Please indicate if you are attending with one of the following programs:

Emerging Leaders in Public Health (ELPH)
NC Health Careers Access Program (NC-HCAP)
Summer PreGraduate Research Experience (SPGRE)
Other program (Please indicate: )
Not with a program

Country:

USA

Canada

Mexico

Other :

State:

State(if USA):

State(if not US):

Postal code:

Agency:

Type of agency:

	Local Health Dept.		Other Government/Municipal Agency
	Managed Care		Hospital/Medical Practice/Nursing Home
	Educational/Research/AHEC		Community/Consumer/Advocacy/ Philanthropic
	Business/Commercial		Professional Society

Job title/ position:

Occupation:

Comments
(no URLs, please):

If applicable, may we quote you (anonymously or with whatever identification you included with your comment) on our website?
Yes No

To Register:

Click the REGISTER NOW button (below), OR
Print, complete, and fax this form to 919-966-2089, OR
Print, complete, and mail this form to:

Minority Health Project
Department of Epidemiology, School of Public Health
University of North Carolina at Chapel Hill
McGavran-Greenberg, CB# 7435
Chapel Hill, NC 27599-7435

Privacy Notice: We at the Minority Health Project respect your privacy. You will never receive any unwanted email or postal mail as a result of the information you have given to us. Minority Health Project does not sell, rent or give any identifiable personal information to any third party.

Admission to School of Public Health programs is without regard to race, sex, national origin, color, religion, handicap, age or veteran's status.

If you have any questions about this conference or registration, please send email to Minority_Health@unc.edu.

Return to the Videoconference home page

Last updated: 04/14/2007, 1/30/2008 by Vic