Summer Public Health Research Videoconference

2001 Summer Public Health Research Videoconference
on Minority Health

Register here to be a satellite downlink site

Note: your on-line registration indicates your acceptance of the Site Agreement. The Site Agreement covers, among other matters, permitted use of materials and recordings from the Videoconference.
There will be no site fee this year.

Organization (* = required field)

*Organization name	Organization type

Web site (if your video facility has a web site, please provide the specific URL
so that we can include a link to it on our web site)

Postal address:	City	*State	Zip code

If a different address is needed for delivery by Federal Express, UPS, etc, please provide it here

Express address:	City	State	Zip code

Viewing Location (where the program will actually be viewed at your site)

Name of facility (if different from organization name)	Number and/or name of room/auditorium

Street address of viewing location (if different from above)

Street address:	City	State	Zip code

How many people can the room accomodate?

Will members of 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
- this person's name and contact information will be placed on our web site
unless you request otherwise (*) = required field):

*First name	Middle name	*Last name	*E-mail

Would you like to receive announcements (maximum 12 / year) about minority health / public health
events available via satellite or Internet? Yes No

Telephone	Fax	Website

How did you first learn about the 2001 video conference?

Comments

Do you agree to the terms of the Site Agreement? Yes No

Technical Coordinator ( the person to whom the satellite coordinates should be sent):

First name	Middle name	Last name	E-mail

Would you like to receive announcements (maximum 12 / year) about minority health / public health
events available via satellite or Internet? Yes No

Telephone	Fax	Website

Please note:

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 Conference participants at your site and completing the site evaluation we will send following the Conference.

4/01/2001, 4/06/2001km Minority_Health@unc.edu