BCPHR Supplement Interest Form

Supplement Interest Form

Please complete the form to indicate interest in publishing a supplement with BCPHR. Learn more at BCPHR.org.
APPLICANT INFORMATION
Contact Email*
example@example.com
Representative's First and Last Name*

First NameLast Name
Representative Position/Title
Organization*
Organization's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Organization's Country*
Proposed Supplement Title/Subject*
Number of Articles Anticipated in the Supplement

No more than 5 articles6-10 articles11-15 articles
Proposed Supplement Addresses the Following Area(s) of Interest*

Artistic Expression and HealthBody imageChildren/YouthChronic DiseaseDomestic Violence/Intimate Partner ViolenceEnvironmental HealthEpi/BiostatisticsGlobal HealthHealth Care PolicyHealth Commnications and TechnolgoyHealth InnovationHuman RightsImmigration / Refugee HealthInfectious Diseases / ImmunologyMaternal and Child HealthMental HealthMindfulness / Sleep / RestNon-infectious DiseaseNutritionObesity / OverweightOccupational HealthPhysical ActivityPolicing / SurveillanceQuantitative MethodsQualitative MethodsRacial / Ethnic Minority HealthSexual / Gender Minorities / LGBTQIA+Social Determinants of Health / Population HealthSubstance UseTerrorismViolence (inc. Gun Giolence)Women / Girl's HealthOther
Signature*
Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Supplement Interest Form