Medicine in Media 2024: Application Form
Application Form
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Email *
First Name *
Last Name *
What state do you live in? *
Phone Number (optional)(10 digits)
What is your main occupation?
(you can choose more than one option, if necessary)
 *
Required
Primary media organization for whom you write or report (enter name or write "none") *

Briefly describe the nature of your work over the last 3 months about health/medicine/medical research. What is approximate number, topic, length and placement of published pieces (include any newspaper articles, tv sports, radio programs, blog posts, etc.).  
(use less than 250 characters)
 *
Briefly describe your target audience?
(use less than 250 characters)
 *

About how much of your professional time is spent on stories about medicine, health or science?
*
Education and training 
(check all that apply)
 *
Required
Why do you want to attend this workshop?
(use <400 characters)
 *
What do you hope to gain from participation?
(use <400 characters)
 *
How did you hear about the workshop?
(use <200 characters)
 *

Please note any potential conflicts of interest (e.g., funding or employment by pharma, device manufacturers, specialty societies) or write "none". 
(use <200 characters)
*
Would you need lodging for the workshop? *
Can you commit to attending the entire workshop? *
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