Virtual Program 2020 Registration

for
African American/Black and Underrepresented Minority Students Who Want to Become Physicians

Make sure you complete entire form.
Deadline for form submissions is Friday, August 14, 2020 at 9:00 P.M. PST

First Name

Last Name

Important: Double check your email to make sure it is listed correctly. This is the only way you will be admitted to the virtual program so please make sure this is the email you will be using.

Important: Please make sure you are the students registering for the program. Parents/guardians, please do not register your email address for your students. Students should only submit an email address they will use.

Home Phone

Cell

Important: Make sure that the number you provide is correct and one you will have access to the day of the program.

City (you live in)

County (you live in)

Age

Date of Birth

Gender Identity

Female Male Prefer not to state Other

Please specify:

Are you Native-born Black American?

Yes No

Are you African (origin in black racial group)

Yes No

Please list Ethnicity/Origin/Country

If not native born Black American/African, what is your Race/Ethnic Background (Check all that apply.)

Native American Samoan Tonga Fiji Filipino Guam Mexican Puerto Rican Hispanic/Latino (non-mexican) Hawaiian Mixed Ethnicity (i.e. Black and Caucasian)

If Native American, please list tribe(s)

If Hispanic/Latino (non-mexican), please list Ethnicity/Origin/Country

If Mixed Ethnicity, please list what they are

Name of University/College/High School attending in Fall 2020

Year of University/College/High School

Freshman Sophomore Junior Senior Post Baccalaureate MPH MBA Other

If other, please identify

What type of doctor do you think you would like to be? (Please check all that apply)

Allergy Anesthesiology Cardiology Dermatology Family Practice Ear, Nose & Throat Emergency Medicine Epidemiology General Surgery Gastroenterology Immunology Infectious Disease Internal Medicine Neurology Neuro Surgery OB-GYN Oncology Orthopedic Surgery/Sports Medicine Pediatrics Physical Medicine and Rehabilitation Plastic Surgery Psychiatry Public Health Pulmonary Medicine Radiology Research Rheumatology Thoracic and Vascular Surgery Urology Other

If other, please identify

Would you like to pick up a printed copy of the workshop presentations prior to the workshop?

Yes No

If yes, you will receive an email with the pick-up location. Please remember to frequently check your spam/junk folder.

Virtual Program 2020 Registration

for
African American/Black and Underrepresented Minority Students Who Want to Become Physicians

Thank you for your interest in this event.
Registration is now closed.
Please check back for future events.

About

Programs

Scholarships

Other Info

Virtual Program 2020 Registration

for African American/Black and Underrepresented Minority Students Who Want to Become Physicians

Thank you for your interest in this event. Registration is now closed. Please check back for future events.

for
African American/Black and Underrepresented Minority Students Who Want to Become Physicians

Thank you for your interest in this event.
Registration is now closed.
Please check back for future events.