Your first name: Last name:

Your title:

Organization:

Email address:

Phone number: Fax number:

Mailing address:

Web site:

1) How do you want to be involved?
Student/Trainee
Mentor/Trainer
Research Partner
Training Site Partner

2) What is your area of interest and/or expertise? What health disparity topics or issues are you interested in working on?

3) What is your educational and/or work experience? What skills and knowledge would you like to share or like to acquire?

4) What is your timeframe for participation? For example, when would you like to get started? How much time can you commit (per week, per month, and/or per semester)?

5) Please provide additional comments here: