Title:   Dr. Mr. Mrs. Ms.    First Name:     Middle Initial:     Last Name:  

Street address:     Email (if available):  

Phone number:  

Affiliation:

High School     College undergraduate    Public Health     Social Work     Law School    
Business School     Graduate School (please specify):  
Medical School (U of M) Medical School (please specify):  

Community member     Hospital     Other (please specify):  

Will you be attending the health screenings?    Yes    No
If yes, which ones?
Cholesterol    Blood pressure    Diabetes    Glaucoma    Hepatitis B    Breast cancer

(Note: registration for the free screenings helps UAAMSA prepare for the event, but does NOT guarantee you a spot. Screenings are available on a first come, first served basis. If you are participating in the cholesterol screening, please do NOT eat breakfast before the health fair.)

Will you be attending the lunch and keynote address?    Yes    No

Will you be attending the workshops?    Yes    No

Some workshops have a limited number for enrollment. Please indicate if you would like to attend any of these workshops. We will select at random and notify you the day of the fair.

  Medical Student Question and Answer Panel
  "Cha-no-yu," A Traditional Japanese Tea Ceremony