HDEART HEALTH EQUITY SCHOLARS & ALUMNI NETWORK REGISTRATION FORM

HDEART HEALTH EQUITY SCHOLARS & ALUMNI NETWORK REGISTRATION FORM

Please fill in the form below.
Full Name *

Prefix First Name Last Name
Middle/Maiden Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home Phone Number *

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

Yes No
Cell Phone Number *

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

Yes No
Fax Number

Area Code Phone Number
May we provide your Fax Number to other alumni?

Yes No
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 Scientist Clinical Scientist Behavioral Scientist Social Scientist Health Policy Community Advocate Physical Scientist Physician Nurse Public Health Health Service Scientist Allied Health Provider Cancer Survivor Epidemiologist
If the answer is other, please explain
Were you a member of the EGL/CRMH/DHCHEER Faculty, Staff and/or Trainee? *

Yes No
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 Student College Student Graduate Student Postdoctoral Fellow Sabbatical Other N/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 Series Disparities in Health in America Course Disparities in Health in America Workshop Intercultural Cancer Council Diversity in Life Science Programs CANDO HOUSTON Southwest Regional Health Equity Council - Region VI Other N?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 *

Yes No
If the answer above is yes, please indicate what you are doing.
Are you presently at an Academic Institution? *

Yes No
If yes, please provide the name of the institution and the department you are affiliated with
What is your position?

Trainee Staff Faculty Other N/A
If other, please list here
If faculty, what is your current position?

Assistant Professor Associate Professor Professor Instructor Other
Do you also hold an Academic Administrative title (Chair, Director, Section Chief, etc.?

Yes No
If so, please indicate here
Were you a CRMH Pipeline High School or College Student *
Are you a HDEART C Institutional Representative? *

Yes No
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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