OFFICE OF DIVERSITY

MINORITY HEALTH PROFESSIONS OPPORTUNITY DAY
REGISTRATION FORM
October 21, 2006
 

PERSONAL INFORMATION


Last Name
First Name
Middle and/or Maiden 		  

 

ADDRESS

Street and No.

Unit

   
City StateZip Code    
   

Email:

   

EDUCATION
 School you currently attend and anticipated graduation date.

High School

Graduation Date

 

 

Choose three hands-on sessions that you would like to attend.  We encourage you to choose a variety of sessions as you may discover something new that you are interested in studying.  Once registered, you will receive a schedule that will include the times that you will be attending each session.

    Basic Sciences/Graduate School                       Medicine
    Nursing                                                            Physical Therapy
    Physician Assistant/Child Health Associate        Public Health
    Dentistry                                                          Pharmacy
 

   

In order to attend Minority Health Professions Opportunity Day a Release From Responsibility Waiver Form must be signed by your parent or legal guardian.

Registration must be received by UCD Office of Diversity by October 13, 2006.

Return Registration To:
University of Colorado Denver
Office of Diversity
4200 E. 9th Ave.
Mail Stop A049
Denver, CO 80262
Phone: 303.315.8558
Fax: 303.315.3253


Thank you for completing this form.