Student Created
Wednesday, August 31 2016
Test-DO NOT USE
Contact the event organizers: JORGE MARTINEZ
Email
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Password
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Confirm Password
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Program Name *
CBET Program Name
First Name *
Last Name *
Gender (select one) *
Gender not listed above
Birthdates *
Street Address *
City/Town *
State *
Zip Code *
Primary Phone # *
Current University Email Address
Racial background (select all that apply) *
Race not listed above
Ethnicity *
Are you a veteran?
Can you answer yes to any of the following?
In which kind of community did you grow up?
Emergency Contact Name *
Emergency Contact Relationship *
Emergency contact Phone *
In what institution or health career program are you currently enrolled? *
Other institution or health career program name
Anticipated Date of Graduation/Completion *
Please select your enrollment year/status: *
Other enrollment year/status not listed above:
Questions from this point on should be fill out by CBET participants only
Please select the health profession program in which you are enrolled:
Nursing specialty or other
I intend/plan/would like to work in a primary care setting (i.e., Family Medicine, General Internal Medicine, General Pediatrics, OB/GYN, General Dentistry, Community Pharmacy).
I intend/plan/would like to work with people who are medically underserved (people who face economic, cultural or linguistic barriers to healthcare).
I intend/plan/would like to work in rural areas.
Account Creation Date *
Authorization and consent: I certify that the information provided is accurate. The CT AHEC Network, UConn, UConn Health and its agents are given my permission to reproduce for publications, presentations, and internet use any photos taken at program functions. If I choose to withdraw my permission, I must provide written notification. Enter your name and Today's Date *
Message to Organizer