Registration Information: ( * indicates required information) |
| Events: |
Women's Health Conference $40.00
Student Price (Valid school ID required at door) $20.00 |
| First Name: * |
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| Last Name: * |
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| Email:* |
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| Phone:* |
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| Address:* |
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| City:* |
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| State/Province:* |
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| Postal Code:* |
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| Would you like to be on our email list? : |
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| Have you attended the OHSU Women's Health Conference in the past? :
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| If you have, how many times? : |
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| Age: |
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| How did you find out about the conference? |
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| Are you an OHSU employee? |
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| OHSU Mail Code (if OHSU employee): |
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| Have you or an immediate family member ever received care at any OHSU facility? |
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| Have you or any immediate family received care in the OHSU Center for Women's Health? |
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| Annual household income before taxes: |
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| How do you describe your race and ethnicity? (choose one or more) |
| White: |
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| Black or African American: |
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| American Indian or Alaskan Native: |
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| Asian: |
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| Native Hawaiian and Other Pacific Islander: |
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| Hispanic or Latino: |
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| Other: |
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| Do you have a disability or impairment? |
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