HDEART HEALTH EQUITY SCHOLARS & ALUMNI NETWORK REGISTRATION FORM

HDEART HEALTH EQUITY SCHOLARS & ALUMNI NETWORK REGISTRATION FORM

Please fill in the form below.
Full Name*

PrefixFirst NameLast Name
Middle/Maiden Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number*

Area CodePhone Number
May we provide your Home Phone Number to other alumni?

YesNo
Cell Phone Number*

Area CodePhone Number
May we provide your Cell Phone Number to other alumni?*

YesNo
Fax Number

Area CodePhone Number
May we provide your Fax Number to other alumni?

YesNo
E-mail*
Alternate Email (this important if you are a trainee and graduate or change jobs
How would we classify you? Click all that apply*

Basic ScientistClinical ScientistBehavioral ScientistSocial ScientistHealth PolicyCommunity AdvocatePhysical ScientistPhysicianNursePublic HealthHealth Service ScientistAllied Health ProviderCancer SurvivorEpidemiologistOther
If the answer is other, please explain
Were you a member of the EGL/CRMH/DHCHEER Faculty, Staff and/or Trainee?*

YesNo
If the answer above was no, how are you associated with EGL/CRMH/DHCHEER.
If you were and/or being mentored by someone associated with the EGL/CRMH/DHCHEER, Please indicate here
If you spent any time in the Experimental Gynecology Laboratory (EGL), Center for Research on Minority Health (CRMH) and/or the Dorothy I. Height Center for Health Equity & Evaluation Research (DHCHEER) please answer the following questions
Check All That Appy*

High School StudentCollege StudentGraduate StudentPostdoctoral FellowSabbaticalOtherN/A
If the answer above is other please indicate your role
If you spent time in the EGL/CRMH/DHCHEER what years were there? (i.e., 2001- 2002)
Please check all of the programs you participated in*

Biennial Symposium SeriesDisparities in Health in America CourseDisparities in Health in America WorkshopIntercultural Cancer CouncilDiversity in Life Science ProgramsCANDO HOUSTONSouthwest Regional Health Equity Council - Region VIOtherN?A
If any of the programs are checked, please indicate the years you attended - 2001, 2002, etc.
If other is check, please list the health disparities/equity programs you have been involved with and the year or years you were active in that program.
If you were a trainee, what academic institution were you registered at while attending the course &/or workshop or the program you were active
Are you still active in addressing health equity issues*

YesNo
If the answer above is yes, please indicate what you are doing.
Are you presently at an Academic Institution?*

YesNo
If yes, please provide the name of the institution and the department you are affiliated with
What is your position?

TraineeStaffFacultyOtherN/A
If other, please list here
If faculty, what is your current position?

Assistant ProfessorAssociate ProfessorProfessorInstructorOther
Do you also hold an Academic Administrative title (Chair, Director, Section Chief, etc.?

YesNo
If so, please indicate here
Were you a CRMH Pipeline High School or College Student*
Are you a HDEART C Institutional Representative?*

YesNo
If yes, please provide the name of the institution you are affiliated with
ACADEMIC HISTORY
Please indicate where you are in your academic and/or professional career, i.e., presently a junior at XX University, 2nd year medical school at XX, completed my training and working for XX, etc.
What are your future career plans?*
Academic Achievement, Honors, Awards
What would you like to received from becoming a member of the Health Equity Scholars & Alumni Network?
CURRENT STATUS
If you are not in Academics, please provide us with an idea of what you are presently engaged in.
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HDEART HEALTH EQUITY SCHOLARS & ALUMNI NETWORK REGISTRATION FORM

ACADEMIC HISTORY

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