Morehouse School of MedicineCommunity Engagement DayParticipant Registration

Morehouse School of Medicine

Community Engagement Day

Participant Registration

Please join us for our Annual Community Engagement Day!

October 22, 2022

10AM - 2PM

Antioch Urban Ministries, Inc

590 North Ave NW

Atlanta, GA 30318

First Name*

Last Name*

Email Address*

Cell Number*

Phone

Name of Group or Organization (if applicable)

Mailing Address*

City*

State*

Zip Code*

County*

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Number of participants with you (including you)

Choose your affiliation (select all that apply)*

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Describe 'other'

Participated in past MSM Community Engagement Day?

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Participated in any previous MSM event?

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Age range

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Fully COVID-19 vaccinated? (Booster not required)*

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MSM Required Event Protocols (Both items are required)

Confirmation that you are fully vaccinated is required and the booster is highly recommended
Submit a COVID-19 PCR test or an antigen test that is not older than 3 days from the date you will come onsite

Send me a copy of my responses