Free Registration for 2003 Minority Health Conference

Saturday January 25th, 2003

 

    

 First Name: ___________________________________

Last Name: ___________________________________

 

Address: _____________________________________

 

City: _____________________________ State: ______

 

Zip : __________ Telephone #: _______________

 

Email: _______________________________________

 

___ Medical Student          ___ Undergraduate    

___ Health Professional    ___ Other: _________________

 

School: _____________________________ Year: ________

 

Ethnicity______________________

 

Where did you hear about the conference?

___On-campus flyer     ___Word of Mouth  ___Email

___Pre-medical Office  ___Newsletter

___Other: _______________________________

 

Ethnicity: (you may mark more than one)

___  Black or African-American       ___  Hispanic or Latino

___  Asian or Asian-American          ___  American Indian

___  Native Hawaiian and Other Pacific Islander

___  White or Caucasian        ___  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

    

 

Workshop Sign-up (Plase choose

1 per block)

 

 Workshop Block 1

___  Cultural Competency

___  Chronic Conditions Panel

___  Minority Mental Health

Workshop Block 2

___ Plight of the Minority 

           Medical Applicant

___ Pharmacological Effects of

            Traditional Remedies

___  Minority Activism

____________________________________

Registration Deposit

 

___$10 Early registration deposit

  • This deposit will be refunded at the conference, thus the cost is FREE

  • Postmarked by January 22, 2003

  • Without early registration, there is a $5 On-site Registration Fee that will not be refunded.

____________________________________

Mentoring Program 

 

For pre-medical students:

___Yes, I am interested in being matched with a mentor.

 

 For medical students:

___Yes, I am interested in being a mentor