Rethinking Race 2016: African Ancestry and High Risk/Triple Negative Breast Cancer Registration Form
NOTE: NEW TIME AND LOCATION!!!
Tuesday, February 2, 2016
6:00 - 7:00pm
Quaker Station, The University of Akron
Sponsored by ARI-AHEC and the College of Health Professions, The University of Akron.

Information for this form is provided voluntarily, but assists us in planning for this and future events. AHEC is required to report aggregate (group) information about program participants, but your personal contact information is not shared beyond this office. Data will be kept private to the extent allowed by law and will be referenced periodically to evaluate the effectiveness of AHEC services and programs.

First Name
Your answer
Last Name
Your answer
Email Address
Your answer
Participant Type
Healthcare Professionals: Employer Name
Your answer
Faculty and Students: University
Registering for a group? Enter number of attendees here.
ALSO: Be sure you share your email with us above in case we need to reach you!
Your answer
Registering for a group? Describe group here.
Example: community nursing class, neighborhood group, etc.
Your answer
Are you employed by or work in the following:
Health Profession Discipline
Fields determined by HRSA, State AHEC offices.
Would you like to be notified of future events?
Submit
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