Black Men In White Coats: General Registration

This registration form is for community members, healthcare professionals, BHSU volunteers, and other event volunteers. 

Name and Contact Information

Salutation

Please select... Dr. Mr. Mrs. Ms. Rev.

First Name

Last Name

Suffix

Please select... Jr. Sr. III

Email

Verify Email

Age

I am a:

Please select... Community member Healthcare professional BHSU student volunteer Event volunteer Event vendor Other

Please explain "Other":

Organization

BHSU major

Type of Health Professional (e.g. Doctor, Nurse, Epidemiologist, Administrator, etc.)

Specialty/Area of Expertise

Licenses and Degrees Earned

Dietary restrictions: Please identify any dietary restrictions such as vegetarian/kosher/gluten-free/peanut-free, etc.

Would you like to receive information about HealthCORE events?

YesNo

Would you like to receive information about BHSU events?

YesNo

Can we share your email with our event vendors?

YesNo

By registering for this event, I understand that photography, videography, and news media for publicity may be present at the event. I consent to allow event representatives to use any media taken during this event for any and all purposes to include publicity. 

Check box to confirm

By registering for this event, I affirm that I am age 18 or older and consent to participate in this event. I acknowledge that I must abide by the policies and guidelines of the event hosts. 

Check box to confirm