2019-2020 Community Driven Research Day Registration Form – Non-Presenters
Instructions: This form should be completed if you would like to attend Community-Driven Research Day. Please complete this form in its entirety.

Community Driven Research Day
DATE: December 9, 2019
TIME: 9:00am - 12:00pm
LOCATION: Jefferson Alumni Hall, Eakins Lounge
1020 Locust St
Philadelphia, PA 19107

More information: https://injury.research.chop.edu/violence-prevention-initiative/other-violence-prevention-programs-chop/community-driven-research-day#.W8jfrXtKiUk
Contact Information
Name *
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Institution/Organization *
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Position *
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Street Address *
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State *
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Zip Code *
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Telephone *
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Email Address *
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Are you a student? *
If you are a student, select type
If you are a student, please provide your major/minor or discipline
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Research Background
In which area(s) are you interested in partnering? *
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Provide a brief description of your research background and current interests: *
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Summarize how your involvement in Community-Driven Research Day can help further your research interests / List your expectations for the day: *
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How would you be able to assist a Community Based Organization / Community Group further their work? *
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How did you hear about Community-Driven Research Day?
If you heard about Community-Driven Research Day through a listserv, please tell us which one:
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Community Driven Research Day is intended to be an open forum for sharing ideas and this conference will do its best to ensure that all participants respect the original ideas of others.
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