Participant registration for the 12th Annual Summer Public Health Research Institute and 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

12th Annual Summer Public Health Research Institute and Videoconference on Minority Health

Please register here to view the webcast (info)
or to attend the Videoconference at UNC-CH (info)

Viewing location:
(required)

Internet/webcast (either day)

University of North Carolina at Chapel Hill (please check one or both, below)

Monday, June 26 (Sonja Haynes Stone Center for Black Culture and History) (where?)

Wednesday, June 28 (SPH Michael Hooker Research Center) (where?)

Satellite downlink site - please insert the Site ID:
           [please find the site you plan to attend on the list of downlink sites;
                the SiteID appears in parentheses immediately after the name of the
                 the site; it is usually the 9-digit postal code]

(the following requested information helps us to evaluate the event; if you have already completed the form once and are returning to view the webcast, please fill in the same e-mail address as the first time, so that we can count viewers accurately) [the email address is the only required field for webcast viewers; if you prefer anonymity, please enter anything in this field, without a "@"]

E-mail address:

(required - but can be fictitious)

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.)

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:

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

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: 05/23,24/06, 6/14/2006 by Vic