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Colorado Collegiate Health Professional Development (CO-HPD)
Faculty Advisor Training
at University of Colorado - Anschutz Medical Campus



When: July 23-July 25, 2014
Location: Anschutz Medical Campus, Aurora 80045
Contact: Jennifer Hellier, Director of CO-HPD 303-724-7865
Chasa Mead, Administrative Assistant 303-724-6489
Registration Deadline: July 15, 2014
Completing this form will secure your lodging at:
Springhill Suites by Marriott, Denver/Aurora/Anschutz Medical Campus, 13400 E. Colfax Ave. Aurora, CO. 80011
(CO-HPD will pay for lodging/meals of faculty advisor only; other family/guests accompanying faculty advisors are responsible for their own meal expenses and any additional lodging.)

Please note that we cover housing costs for participants coming from outside of the Denver Metro area. In the event that you need to cancel your registration, please let us know as soon as possible so that we do not end up paying for unused rooms. To cancel, please contact Michaels Flowers at (303) 724-6489 or michael.flowers@ucdenver.edu.
First Name:
Last Name:
Address 1:
Address 2:
Address 3:
City/State/Zip: / /
* Work Phone: - -
* Cell Phone: - -
Email:
School Type:
High School
2-Year College
College/University
School Name:
Number of Student Advisees:
Need Lodging:
Yes
No
Room Preference:
King
Double
Lodging for 7/23/14:
Yes
No
Lodging for 7/24/14:
Yes
No
This activity is sponsored by the Department of health and Human Services - Health Resources and Service Administration grant (HRSA.gov) and the following information is required to be collected according to the 3-yr approval from the Office of Management and Budget (OMB). Bureau of Health Professions Performance Date Collection (OMB No. 0915-0061). For more information please see http://www.gpo.gov/fdsys/pkg/FR-2013-04-01/pdf/2013-07455.pdf.
* Age:
* Gender: Male
Female
* Race: Check All That Apply
American Indian or Alaska Native
Asian
African American
Native Hawaiian or Pacific Islander
White
* Are you hispanic? Yes
No
* What is the highest level of education you have completed?
* Please select a response that best describes the community in which you were RAISED? Urban/Suburban
Underserved Area (urban)
Rural/Small Town
Underserved Area (rural)
Not Sure
* Are you from a disadvantaged background (come from a family with an annual income below a level based on US low income thresholds or come from an environment that has inhibited you from obtaining the knowledge, skill, or abilities required to enrol and graduate from a health professions school)? Yes
No
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If you have any trouibl with this form, please contact joseph.martinez@ucdenver.edu.
 

 
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