2025 Public Health Leadership and Medical Academy Institute Form

Public Health Summer Institute and Medical Academy

Get Ready to Build Your Public Health Skills This Spring and Summer 2025!
Participant Information
Scholarships are available. Contact communications@bcph.org for details.

If accepted, you will need to provide the following forms, which are available here: https://bcph.org/institute.
- High School Students:
  - Media Release Form
  - Student Code of Conduct/Honor FormStudent Waiver Form
- Undergraduates/Post-baccs: Media Release Form only
- Community Members: Media Release Form only
Participant Name*

First NameLast Name
Name of Current School/University/Organization*
City and State of High School or Organization*
Current Grade Fall 2024 or Professional Title*
Preferred Email for all correspondences*
Secondary email for correspondences*
Referral if applicable
Any physical accommodations needed for the in-person sessions? Any food allergies or preferences (e.g. vegan/vegetarian)?*

Yes - I will email communications@bcph.org with the specific detailsNoNot applicable - not attending in person
If attending in person, which public health summer institute will you be attending?*

Online-Only Session: April 25-27In Person, Hybrid Washington, DC Session: June 25-29Online, Hybrid Washington, DC Session: June 25-29
File Upload of 3-5 minute video of yourself, why you want to attend the Institute, and what Public Health, Social Justice, and Clinical Medicine mean to you.*

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File Upload of Current Photo*

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Upload Unofficial Transcript*

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Confirmation

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

I ACKNOWLEDGE THAT I HAVE READ THE PRIVACY, REGISTRATION, AND 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.

REFUNDS ARE PROVIDED IN FULL IF THE PARTICIPANT IS NOT ABLE TO ATTEND THE INSTITUTE. IF THE PARTICIPANT ATTENDS SOME OF THE INSTITUTE AND NEEDS A REFUND, A PRORATED REFUND WILL BE GIVEN.
Please verify that you are human*
Date*

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Public Health Summer Institute and Medical Academy

Participant Information