Global Health Affiliate Registration Form

1. Last Name 

2. First Name 

3. Health Field

Medicine  Nursing   Pharmacy  Public Health  Veterinary Medicine
Other Health Related Field ( Please specify)  

4. Affiliation

  UW Faculty or Staff
  UW Student
  Community Affiliate

5. Health Topics on Interest (check all that apply)

  Maternal and Child Health and Reproductive Health
  Infectious Disease
  Nutrition
  Chronic Disease and Injury
  Mental Health
  Environmental Health
  Humanitarian Emergency Response
  Veterinary Medicine
 Other (Please specify)  

6. Geographic Regions of Interest/Experience (check all that apply)

  Africa
  Asia
  Europe
  Latin America
  Middle East

7. Country Specific Interest/Experience

8. Language Skills

  Arabic
  Chinese
  French
  Spanish
  Portuguese
Other (Please specify) 

9. Type of Work (check all that apply)

  Clinical Service
  Training
  Research
  Consultation

10. Briefly describe your areas of expertise and interest