Chicanos/Latinos for Community Medicine at UCLA
"Empowering the future of health since 1970"

Membership Application

Last Name *
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First Name *
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Email *
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Phone Number *
xxx-xxx-xxxx
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Hometown *
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Age *
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Major *
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Minor *
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Year *
Graduating Year *
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Are you a transfer student? *
Racial/Ethnic Background *
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What are your professional goals? *
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Are you a returning member? *
If you are a returning member, have you been placed in a CCM Familia?
What is the name of your CCM Familia if you are in one?
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How did you hear about CCM? *
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What do you hope to gain from CCM? *
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If you are a returning member, how do you think CCM can improve?
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Additional Comments?
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