*1.Name of Applicant:(Required.)

*2.Name of Institution: (Required.)

*3.Title:(Required.)

*4.Email Address: (Required.)

*5.Country:(Required.)

*6.Degree/Credentials:(Required.)

*7.Are you a current student or trainee?(Required.)

Yes

No

8.If yes, please briefly describe your program (e.g. MSN program, medical residency, DACM program, etc.)

*9.Please check all eligibility criteria that apply:(Required.)

Black or African American

Hispanic or Latino

American Indian

Alaska Native

Native Hawaiian

Pacific Islander

Individual with disabilities (defined as those with a physical or mental impairment that substantially limits one or more major life activities)

Other: Do you feel you are part of an underrepresented group not listed here? For consideration, please apply and explain.

10.If you selected "Other" from the eligibility criteria above, please use this area to explain your reasoning:

*11.How will your participation at the Integrative Medicine & Health Symposium contribute to your professional growth?(Required.)

*12.How will you plan to share knowledge from the Integrative Medicine & Health Symposium in your work or academic studies?(Required.)