Haku Healthcare American Indian Student Summit Event Registration
Event Timing: March 30, 2019 from 8:00am - 6:00pm
Event Address: Santa Ynez Chumash Tribal Hall, 100 Via Juana Lane, Santa Ynez, CA 93460
Contact Dr. Stern at nstern@sansumclinic.org for any questions.
Email address *
Name *
Your answer
Age (as of March 30, 2019) *
Your answer
Tribal Affiliation(s) *
Your answer
Your answer
College Major or Career Focus? *
Your answer
What is your grade or college/university level?
Your answer
Address *
Your answer
Phone *
Your answer
Are you able to attend the full day 8am-6pm? *
Dietary restrictions (if any)? *
I understand that registration is FREE (includes breakfast, breaks and lunch), but I will have to make my own arrangements regarding travel or lodging (if necessary). *
FOR PRE-HEALTH CARE CAREER/PRE-PUBLIC HEALTH/COLLEGE STUDENTS/EARLY CAREER STUDENTS ONLY: Write a 400 word maximum paragraph about why you would like to attend the Haku Healthcare American Indian Student Summit.
Your answer
FOR MEDICAL STUDENTS ONLY (check all that apply):
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