Midwestern Summit form

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Event Timing: June 10, 2024; 10am-2pm
Event Location: Midwestern College of Dental Medicine - 19555 N. 59th Ave., Glendale, AZ 85308
Contact us at info@diversityindentistry.org for any questions

Please answer the following questions to register for the Diversify Dentistry Summit

BY MAY 31, 2024. Details will be emailed to you the week before the event.

First Name *

Last Name *

Phone Number *

Email *

It is important for us to pronounce your name correctly. If you feel there is any way that this may not happen please provide a phonetic spelling of your name.

For example:
Raul Gonzalez: rah-OOL gon-SAH-les

Sophia Lamagna: so-FEE-uh sounds like “lasagna”

How did you hear about the Summit? *

AACHC

American Indian Student Support Services at ASU

Future Stars AZ

Midwestern

Diversity in Dentistry Mentorships

Friend or 'word of mouth'

Social Media

Other:

Required

Adult Shirt Size *

School *

Grade/Education Level
*

Age. (I understand that if I am 16 or 17 years old, my parent will need to physically sign me in the day of the event) *

Race or Ethnicity
*

Hispanic or Latino

Black or African American

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

White or Caucasian

Asian

Other:

Required

Have you considered pursuing a career in dentistry?
*

Given your race and ethnicity, have you seen your ethnic background represented in the field of dentistry?
*

Please share any questions or comments you have:

I understand that transportation is NOT included. *

By submitting this form, I am committing to attend the event. (A confirmation email will be sent to you the week before the event) *

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