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Digital Health Equity Ambassador Program Interest Form
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* Indicates required question
Last Name
*
Your answer
First Name
*
Your answer
Email
*
Your answer
Phone number
*
Your answer
Linked-in URL
*
Your answer
Academic Institution Graduating(ed)
*
Your answer
Academic Grade Level
*
Freshman
Sophomore
Junior
Senior
Graduate
PhD
International Medical Graduate
First-Generation to go to College?
*
Yes
No
Required
How did you hear about this program?
*
LinkedIn
Podcast
Peer/Colleague
Conference
Instagram
School
Networking Session
Other
Required
If Other, can you specify?
Your answer
Have you ever taken a digital health equity curriculum or course?
*
Yes
No
If yes, where did you learn about digital health equity?
Your answer
What do you wish to get out of this program? (ex: learn about DHE, Research, Job Opportunities, etc)
Your answer
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