NC Institute for Public Health, UNC School of Public Health

27th Annual Minority Health Conference
Satellite Downlink Site Registration form
(If you have previously registered to downlink the Annual UNC-SPH Minority Health Conference
or the Annual Summer Public Health Research Videoconference on Minority Health,
you may use our Express Registration form )
Organization (* = required field)
   *Organization name    Organization type

    Web site URL for your organization

    Does your organization's primary mission specifically involve
African Americans?   American Indians/Native Americans?
Asian/Pacific Islander Americans? Hispanic/Latino Americans?

  Postal address     City 
    State (if USA)                     *     State or province (if not USA)     *Postal code (all parts)
    -
    Country
    USA     Canada     Mexico         Other     If Other, Please Specify

Viewing Location (where the program will actually be viewed at your site - if different from above)
    Name of facility     Number and/or name of room/auditorium

    Street address of viewing location (if different from Organization address)
   Street address    City
    State    Postal code    (all parts)
-

   How many people can the room accomodate?  
   Will the public be welcome to attend? Yes No     Are you taping only? 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):
  *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 conference?
   

Technical Coordinator ( the additional 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


    Comments   

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 read the site agreement.

 

 
Office of Continuing Education | North Carolina Institute for Public Health
Campus Box 8165 | UNC School of Public Health | Chapel Hill, NC 27599
Phone 919-966-4032 | Fax 919-966-5692 | E-mail oce@unc.edu

Last updated: 11/13/05,2/11/2006 by Vic