Public Health Summer Institute FACULTY Form

BCPH Academy Faculty Form
Name*

First NameLast Name
Email*
example@example.com
Pronouns*
Example: She/Her/Hers
Country of Residence*
Country of Origin*
Title*

MD/DOScD/SD/DScPhDJDMAMS/MPHMultiple DegreesIn process degree
Brief Bio (4-5 lines) (Do not use bullet points. Must be in narrative style.)*
Upload CV*

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Upload Professional Headshot*

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Tell us about your proposed course or courses. Please include title as well as outlines sub-topics. *
Proposed area of public health and social justice for course(s)*

Health policyHealth managementMaternal and Child HealthReproductive and sexual healthLGBTQ+ HealthMen's HealthWomen's HealthSubstance Use, Abuse, and AddictionRefugee/Immigrant HealthInfectious diseasesEnvironmental healthOccupational healthDental HealthGlobal HealthDisabilityPublic Health EntrepreneurshipPublic Health LeadershipResearchSurgery/Global SurgeryNA
Proposed areas for pre-medical academy*

The Metaverse and HealthcareMedical Assistance with DyingAll the "omics" of medical researchPalliative SedationOrgan TransplantationBrain Death and Cardiac Death: Protocols and ProceduresTelemedicinePersonalized MedicineGlobal HealthDiversity and Equity in HealthcarePhysician Decision Making for Incapacitated PatientsMedical TourismNA
Demographics

Below are some background questions that help us tailor our programming. You are not obligated to answer.
Gender: I identify as (click all that apply):

ManWomanNon-BinaryTrans genderX
Race: I identify as (click all that apply):

WhiteBlack or African AmericanAsianAmerican Indian and Alaska NativeNative Hawaiian and Other Pacific Islander
Please verify that you are human*
Today's Date: I understand that my submitting this form, I agree that I will produce a course(s) and intend to give it IN-PERSON at one or more of the sessions.*

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BCPH Academy Faculty Form

Demographics