Public Health Institute Interest Form (Students)

Public Health Leadership Institute

Complete the form below to let us know where and when you're interested in attending the Public Health Leadership and Medical Academy Institute (PHI) in Spring and Summer 2025!
PHI Students can elect to be in person or virtual. We also plan to be taking the Institute abroad in 2025-2026.

The training is intended for students for those applying to or attending:
- College
- Graduate school
- Clinical training programs
This is also an excellent training program for volunteers and employees of organizations serving marginalized populations and/or addressing the social determinants of health:
- Community and faith-based organizations
- AIDS service organizations
- Substance use clinics
- Housing support entities
- Legal assistance firms
- Planning councils and community advisory boards
Visit us at www.BCPH.org or email communications@bcph.org for more information.

Please note: This is not an application form.
Primary Email*
example@example.com
Secondary Email*
example@example.com
Name*

First NameLast Name
Pronouns*
Example: She/Her/Hers
State*
Postal Code
Country of Residence*
Country of Origin*
Mobile Number
example@example.com
Current Status*

High School Junior or SeniorGraduate/Clinical School ApplicantCollege StudentGraduate/Clinical School StudentPost-baccalaureateNon-profit studentOther
Are you interested in a training for your organization?*

Yes - I'd like more informationNo - N/AOther
Let us know what interested you in the PHI Institute?
Public health and social justice areas of interest. (Select ALL that apply.)*

Health policyHealth managementMaternal and Child HealthReproductive and sexual healthLGBTQ+ HealthMen's HealthWomen's HealthSubstance Use, Abuse, and AddictionRefugee/Immigrant HealthInfectious diseasesEnvironmental healthOccupational healthDental HealthGlobal HealthDisabilityOther
Dates and Locations

Below are some background questions that help us tailor our programming. You are not obligated to answer.
What dates work best for Spring 2025? (Check all that apply.):

March 15-18March 21-23April 25-29
What dates work best for Summer 2025? (Check all that apply.)

May 23-26June 6-9
What locations work best for you? (Check all that apply.)

Washington, DCNew York City (Upper Manhattan), NYBoston, MAVirtual/Online in Real TimeAsynchronous Online
The PHI will be going international! Would you be interested in attending the institute abroad? If so, please indicate where:

Oxford, England, UKKuala Lumpur, MalaysiaOther
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 genderXOther
Race: I identify as (click all that apply):

WhiteBlack or African AmericanAsianAmerican Indian and Alaska NativeNative Hawaiian and Other Pacific IslanderOther
I am /was the first person in my family to go to college.
Age

Under Age 1818-2122-2526-2930-3435-3940-4445-4950-5455-5960+
Please verify that you are human*
Today's Date*

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Public Health Leadership Institute

Dates and Locations

Demographics