JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Event RSVP
Contact Us
Dr. Stephen B. Thomas
Director, Center for Health Equity
sbt@umd.edu
Surayyah Khan
Research Assistant
skhan678@umd.edu
Maryland Center for Health Equity
301-405-8859
* Indicates required question
Biomedical Clinical Trials and the Role of Black Barbershops & Salons in the Recruitment and Retention of African Americans
Name (First Last)
*
Your answer
Can you attend?
*
Sunday, December 8th Reception (5-8:30 PM)
Monday, December 9th Workshop (8 AM - 4:30 PM)
Unable to Attend
Required
Role
*
Shop Owner
Barber
Stylist
Scientist
Funder
Other:
Required
Name of Your Organization (or Establishment)
Your answer
If Barbershop or Salon Owner, How Many Years Have You Been in Business?
Your answer
Are you currently involved in delivering health information through your barbershop/salon or participating barbershops/salons?
Yes
No
Clear selection
Contact Information (email, phone and business address)
*
Your answer
Lunch Preference (Monday Workshop)
*
Herb-Rubbed Chicken Breast with Rosemary and Garlic Roasted Potatoes
Vegetable Quinoa Paella with Pan Seared Tofu Steak, Red Pepper Coulis and Seasonal Vegetables
Do you have any dietary restrictions?
Your answer
Do you have accessibility or mobility concerns? (If so, please provide a short description of your needs below)
Your answer
Comments and/or questions
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of University of Maryland.
Report Abuse
Forms
