The University of North Carolina at Chapel Hill
Gillings School of Global Public Health (link)

 Your guide to minority health-related activities
at UNC-CH and elsewhere 

17th Annual Summer Public Health Research
Institute and Videoconference on Minority Health

Register an organization or group viewing site

 *E-mail address:    
Would you like to receive e-mail announcements? (maximum 12/year, about minority health / public health events)
Yes       No

First Middle Last

City, county
postal code:


*City County
(for NC residents)
Postal code



State (if USA):  State (if not US):

Other :



Agency web site


Type of agency:
Local Health Dept. Other Government/Municipal Agency
Managed Care Hospital/Medical Practice/Nursing Home
Educational/Research/AHEC Community/Consumer/Advocacy/
Business/Commercial Professional Society

Job title /position:




Are you a UNC alum?


Are you affiliated with a program?


  NC Health Careers Access Program (NC-HCAP)
  Summer Public Health Fellowship program (SPHF)
  Other program   - please indicate:
  Not with a program

How did you learn about this event? (check all that apply)


  Printed announcement (above right)
  Email from the Minority Health Project
  Minority Health Project web site
  Other email
  Other web site
  From a group or program
  Flyer (below right)
  Other   (Please indicate:

Printed announcement image of announcement
Flyer image of flyer
Are you registering on behalf of an organization or to show the broadcast to a group?
Yes       Neither of these (if "neither" click here and skip to the end)
For Organizations or Group Viewing Sites
   Organization name (if not given above)    Website (if not given above)
   Name of facility    Number and/or name of
   Street address    City
  *State (if USA)                         State or province (if not USA)    *Postal code (all parts)
    USA     Canada     Mexico     Other   If Other, Please Specify

   How many people do you expect to view the program?  
   Will the public be welcome to attend? Yes No    
   Will there be a registration fee?       Yes       No  amount, if known:
   Does your facility have the capability of disseminating the videocast to other locations and
   would  you like to do so?        Yes      No

Site Facilitator (the person who is responsible for coordinating this event at your site - if not yourself):
    Are you the site facilitator?  Yes      No (please give name, email address, and telephone number here)
   *Facilitator first name Facilitator middle name    *Facilitator last name   
  *E-mail:       *Telephone    
   Should we send announcements to this address (maximum 12 / year) about minority health / public health
    events available via Internet?     Yes  No

Technical Coordinator (if we should send webcast location to someone else):
   First name Middle name Last name

   *May we include your site in the list of viewing sites?
           Please include our site in the list of sites.
           Please include our site but not site facilitator name or contact information.
           Please do not list our site on the web.

As a grant-supported activity our ability to offer these programs depends upon being able to document their value. Please help us by providing an accurate count of the number of broadcast participants at your site and completing the online site facilitator evaluation.

Please note that by registering your site you are agreeing to the site agreement.

("http://" not allowed in comment):


If applicable, may we quote you on our website?
No       Yes (if so, please “sign” your comment if/as you wish it to be identified)

Videoconference home page

Privacy policy: We at the Minority Health Project respect your privacy. You will never receive any unwanted email or postal mail as a result of the information you have given to us. Minority Health Project does not sell, rent or give any identifiable personal information to any third party.

Admission to University of North Carolina programs is without regard to race, sex, sexual orientation, national origin, color, religion, handicap, age or veteran's status.

If you have any questions about this conference or registration, please send email to

Minority Health Project| Department of Epidemiology
UNC Gillings School of Global Public Health
2104D McGavran-Greenberg, CB#7435 | Chapel Hill, NC 27599-7435
Phone 919-966-7436 | Fax 919-966-2089| E-mail

Last updated: 3/21/2011, 4/20/2011, 5/14/2011 by Vic