EqualHealth Interest Form

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Thank you for your interest in EqualHealth. By completing this form you will be added to our general mailing list and lists specific to each of our programs that interest you.
Please provide the information below and if you have any questions please see our website www.equalhealth.org or email us at info@equalhealth.org

Email *

Please provide your preferred email address: *

Please provide your first name: *

Please provide your last name: *

Please provide the name of the institution(s) with which you are most closely affiliated: *

EqualHealth offers a number of programs and activities. Please indicate all areas of interest so we may direct specific communications to you:

Campaign Against Racism

Fellowship in Medical Education

Haiti-based Medical Education Conference

Haiti-based Social Medicine Course

Minneapolis-based Social Medicine Course

Social Medicine Alumni of Haiti

Social Medicine Consortium

Uganda-based Social Medicine Course

Women's Leadership Roundtable

Supporting EqualHealth through fundraising or partnership

Other:

Please indicate your language preference for communications:

English

French

Haitian Creole

Other:

Please tell us how you learned about EqualHealth and any affiliations or connections you have with our work:

Please feel free to add any additional information you would like to share about yourself with EqualHealth:

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