Public Health Leadership VIRTUAL institute

Participant Name*

First NameLast Name

Preferred Email*

Alternative Email*

School/University/Employer*

I am a ...*

I will be attending the following Public Health Leadership Virtual Institute:*

Session 1: March 15-17Session 2: March 22- 29Session 3: April 13-15

Emergency Contact Name/Email/Phone - Must complete if in high school

How would you rate your knowledge of public health?*

1 is Worst, 5 is Best

How would you rate your knowledge of social justice?*

1 is Worst, 5 is Best

Would you like to qualify for the BCPH Research Scholars Program? More info: https://bcph.org/research-scholar/. Please send two recent writing samples to communications@bcph.org with "RE: BCPH Research Scholars Program - Writing Samples" in the subject.*

YesNo

Confirmation

ALL INFORMATION SUBMITTED HEREIN IS TRUTHFUL AND NOT INTENTIONALLY MISLEADING TO THE BEST OF MY KNOWLEDGE.

I ACKNOWLEDGE THAT I HAVE READ THE CANCELLATION DOCUMENTATION AND AGREE TO LAWFULLY ABIDE BY THESE TERMS GIVEN ANY FUTURE ISSUE.

I ACKNOWLEDGE THAT THE BOSTON CONGRESS OF PUBLIC HEALTH (BCPH) IS A SOCIAL JUSTICE ORGANIZATION THAT VALUES AND ESPOUSES THE PRINCIPLES OF DIVERSITY, INCLUSION, EQUITY, AND ANTI-RACISM. I UNDERSTAND THAT BCPH DOES NOT DISCRIMINATE ON THE BASIS OF RACE, ETHNICITY, GENDER, NATIONALITY, SEXUAL ORIENTATION, RELIGION, IDEOLOGY, POLITICAL PREFERENCE, OR OTHERWISE.

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Date*

Date

BCPH Summer Institute Order Form

Public Health Leadership VIRTUAL Institute Cancellation policies will strictly apply.

$500.00 Quantity

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$0.00

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Public Health Leadership VIRTUAL institute

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