STUDENT REGISTRATION: Mi Futuro 2020

The North Bay's

Youth Healthcare Symposium
MF 2020 STUDENT REGISTRATION FORM

January 10, 2020, 9:30am-4:45pm
Before proceeding...read and acknowledge statement below.
Healthcare providers' life work is to establish a long and good life for you and our community. To assure you have equal access to opportunities presented at Mi Futuro, we provide you with a professional level conference and waive the $150 cost of your attendance. You will attend at no-cost. As a respectful partnership, attend boldy, responsibly, and the entire day.
I have read and acknowledge the above statement. I commit to attend boldly, responsibly, and the entire day. *
Sonoma State University
Student Center Grand Ballroom
1801 E. Cotati Ave
Rohnert Park, CA 94928
TABLE TALK STUDENT LEADERS CALLING ALL COLLEGE STUDENTS! SSU & SRJC...DEFINITELY YOU!:

ALL COLLEGE & POST-COLLEGE HEALTHCARE STUDENTS WILL BE ASSIGNED TO A TABLE DURING MORNING SESH TO BE THE "TABLE TALK FACILITATOR". STAGE PANEL SPEAKERS WILL HAVE A "TABLE TALK QUESTION" ABOUT EVERY 15 MINUTES FOR STUDENT DISCUSSION AT ASSIGNED TABLES. (SEE IMAGE BELOW). TABLE TALK LEADERS WILL FACILITATE THAT QUESTION DISCUSSION!
TABLE TALK LEADERS: If you are a college or post-college healthcare student, what will be your future healthcare license?
COLLEGE & POST-COLLEGE TABLE TALK LEADERS WILL RECEIVE A FOLLOW-UP EMAIL WITH FURTHER INSTRUCTIONS.
Current School:*
Current school grade or degree in progress:*
Last Name*
First Name*
Email*
example@example.com
Phone Number

Area CodePhone Number
List food allergies:
Age*
Gender Identification*
Ethnicity*
If you attended last year's Mi Futuro, did you commit to a healthcare career as a result of attendance?*
What healthcare profession are you most interested in today?*
Were you, are you, or will you be the first person in your immediate family to attend college or health career technical school?*

How confident are you in your ability to complete the application process for entry into college or a health career technical school? If you don't plan to attend college or a health career technical school mark "0".*

	0	1	2	3	4	5

0 is NOT AT ALL!, 5 is EXTREMELY Confident

How would you rate your interest in becoming a primary healthcare provider (such as: doctor, nurse, etc.)? If you don't know what a primary health care provider is, mark "0".*

	0	1	2	3	4	5

0 is NOT AT ALL!, 5 is EXTREMELY Interested

How interested are you in serving in a medically underserved area (an area that doesn't have enough money & medical services)? If you don't know what a medically underserved area is, mark "0"*

	0	1	2	3	4	5

0 is NOT AT ALL!, 5 is EXTREMELY Interested

How would you rate your interest in becoming a mental health or substance abuse provider/counselor? If you don't know what a mental health or substance abuse provider/counselor is, mark "0".*

	0	1	2	3	4	5

0 is NOT AT ALL!, 5 is EXTREMELY Interested

How aware are you of financial aid programs for college & health career technical schools available to Californians who are interested in PRIMARY HEALTHCARE careers in medically underserved areas? If you don't know what a medically underserved area is, mark "0".*

	0	1	2	3	4	5

0 is NOT AT ALL!, 5 is EXTREMELY Aware

How aware are you of financial aid programs for college & health career technical schools available to Californians who are interested in MENTAL HEALTHCARE careers in medically underserved areas? If you don't know what a medically underserved area is, mark "0".*

	0	1	2	3	4	5

0 is NOT AT ALL!, 5 is EXTREMELY Aware

What is your COMFORT LEVEL in accessing mental health services as a client if you were experiencing a mental health issue? (If you want to meet with a mental health counselor, do you know where to start?) If you don't know what a mental health issue is, mark "0".*

	0	1	2	3	4	5

0 is NOT AT ALL!, 5 is EXTREMELY Comfortable

Have you or a family member ever used mental health services?*

Rate your COMFORT LEVEL around people with mental health issues? *

	1	2	3	4	5

1 is NOT AT ALL!, 5 is EXTREMELY Comfortable

YOUR 2020 ANNUAL SYMPOSIUM!

CHOOSE 2 WORKSHOPS & 1 MED TRACK BELOW!
2020 WORKSHOPS
College/Career Readiness, Mental Health Wellness

Workshop A: Healthcare Career Pathways

Workshop B: Money & College: Financial Aid, Loan Forgiveness.

Workshop C: Mentors & Internships: How they change your future!

Workshop D: Spiritual Formation & Improved Health

Workshop E: Resiliency Training: Heart Math

Workshop F: Peer-to-Peer: Youth Promotores advocate Mental Health wellness
CHOOSE 2 WORKSHOPS:
2020 MEDICAL LAB STATION TRACKS
Doctor Track #1: Outpatient

1. Primary Care/Family Medicine:Obstetrics
2. Dentist
3. Surgeon
4. Pediatrics

Doctor Track #2: Inpatient

1. Primary Care/Family Medicine:Hospitalist
2. Emergency Medicine
3. Cardio-Pulmonary
4. Orthopedics
CHOOSE 1 MED TRACK
PERMISSION SLIP
High School Students: Have you submitted a signed permission slip to your school's designated teacher/counselor?*
MI FUTURO PHOTO CONSENT

We want to capture the full story & values of our community (and YOU)! Along with your Permission Slip, submit your signed Photo Consent to your school's designated teacher/counselor. (REMEMBER PARENT/GUARDIAN NEEDS TO SIGN)
Have you completed & submitted a signed Photo Consent? *
2020 REGISTRATION

DROP DATE: 11/20/2019

If you are unable to attend as planned, please withdrawal your registration timely to allow other students to attend. Notify your school's contact person & email mifuturonorcal@gmail.com
Mi Futuro 2020

http://www.mifuturonorcal.org
Hit Register Button Below!

We are super excited to see you Friday, January 10th, 2020!
Should be Empty:

MF 2020 STUDENT REGISTRATION FORM

TABLE TALK STUDENT LEADERS CALLING ALL COLLEGE STUDENTS! SSU & SRJC...DEFINITELY YOU!:

2020 WORKSHOPS

CHOOSE 2 WORKSHOPS:

2020 MEDICAL LAB STATION TRACKS

CHOOSE 1 MED TRACK

PERMISSION SLIP

MI FUTURO PHOTO CONSENT