Free Registration for 2003 Minority Health Conference

“Bridging Cultures and Enhancing Minority Healthcare in the New Millennium”

 Tom Bradley International Hall, UCLA

Saturday, January 25, 2003  

 

First Name: ___________________________________

Text Box: Workshop Sign-up (please choose one for each block)  Workshop Block 1 c  Cultural Competency c  Chronic Conditions Panel c  Minority Mental Health  Workshop Block 2 c  Plight of the Minority Medical Applicant c  Pharmacological Effects of Traditional Remedies c  Minority Activism   Last Name: ___________________________________

Address: _____________________________________

City: _____________________________ State: ______

Zip Code: __________ Telephone #: _______________

Email: _______________________________________

 

c Medical Student           c Undergraduate    

c Health Professional     c Other: _________________

School: _____________________________ Year: ________

Ethnicity______________________

 

Text Box: Registration Deposit   c  $10 Early registration          deposit ·  This deposit will be refunded at the conference, thus the conference is FREE. ·  Postmarked by January 22, 2003 ·  Without early registration, there is a $5 On-site Registration Fee that will not be refunded.   Where did you hear about the conference?

c  On-campus flyer     c Word of Mouth    c  Email

c  Pre-medical Office  c  Newsletter

Text Box: Mentoring Program  For pre-medical students: c  Yes, I am interested in being matched with a mentor.  For medical students: c  Yes, I am interested in being a mentor.   c  Other: _______________________________

 

Ethnicity: (you may mark more than one)

c  Black or African-American        c  Hispanic or Latino

c  Asian or Asian-American          c  American Indian

c  Native Hawaiian and Other Pacific Islander

c  White or Caucasian        c  Other:____________________

 

 

 

 

 

 

 

 

 

                                                                                                                                                                                                    

 

 

 

Instructions:    

Please PRINT & MAIL COMPLETED FORM and Check Payable to UCLA APAMSA to:    

2003 Minority Health Conference

c/o Office of Academic Enrichment & Outreach

Box 956990

Los Angeles, CA 90095