UNM HSC Communities to CareersNative American Healthcare Career Expo 2025

UNM HSC Communities to Careers

Native American Healthcare Career Expo 2025

To be held at UNM Health Science Campus on January 31, 2025 from 10:00am to 1:00pm

Student Information

First Name*

Last Name*

Student Email Address*

Student Cell Phone*

Student Address*

City*

Date of Birth*

Sex Assigned at Birth*

Select or enter value

Gender*

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Participant Shirt Size*

Select

School Information

School Name*

Are you participating in Dream Makers?*

Select or enter value

Expected Graduation Year*

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Current Grade Level:*

Select

Career Interest

In your own words, what is your career interest?*

Food Allergies

Please indicate any food allergies or preferences:

Student Demographics

Are you a New Mexico Resident?*

YES

Do you consider yourself to be Hispanic/Latino(a)?*

YES

In describing yourself, please select one or more of the following racial categories:*

What tribe do you affiliate with?*

If "other" please specify*

What language(s) do you speak?*

What was your first language?*

What is the primary language spoken at home?*

Parent Information

For any required sections that you do not have information for please write or select N/A.

Parent/Guardian 1 - Name (first last)*

Does the student regularly live with parent/guardian 1?*

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Parent/Guardian 1 - Phone Number*

Parent/Guardian 1-Email Address*

What is the highest level of education completed by Parent/Guardian 1:*

Select or enter value

Parent Information 2

Parent/Guardian 2- Name (first last)

Parent Guardian 2- Phone Number

Parent/Guardian 2-Email Address

What is the highest level of education completed by Parent/Guardian 2:

Select or enter value

Transportation

Will you be coming with a school group?*

Select

Additional Required Information

Please complete this section with a parent or guardian.

Name of parent or legal guardian:*

Emergency Contact:*

Emergency Contact Phone Number:*

Please indicate below any on-going medical or emotional conditions that may require special attention:*

Primary care physicians name:*

Primary care physicians number:*

Health Insurance Company Name:*

REQUEST TO FOLLOW UP: I grant UNM HSC Office for Diversity, Equity & Inclusion permission to contact me in the future by telephone, mail and/or email provided on the online participation form. I may be contacted after my child has completed this program for the purposes of tracking educational careers.*

Parent/Guardian please type your name (by typing your name you acknowledge our terms and consent the above).

CONSENT TO PHOTOGRAPH/VIDEO RECORD: I do hereby give The University of New Mexico and its designates the irrevocable right to use photographs of my child, and or their property, name (or any fictional name), picture, portrait, or photograph in all forms and media and in all manners, including composite or modified representations, for advertising, trade or any other lawful purposes, without further compensation, and I waive any right to inspect or approve the finished version(s), including written copy that may be created and appear in connection therewith. All negatives, positives, and digital files, together with the prints shall constitute The University of New Mexico’s property, solely and completely. I am of full age. I have read this release and am fully familiar with its contents.*

Parent/Guardian please type your name (by typing your name you acknowledge our terms and consent to the above).

I hereby give permission for my child to participate in the following program:*

The University of New Mexico (“UNM”) offers youth programs through the UNM HSC Office for Diversity, Equity and Inclusion – Communities to Careers Programs. A description of all youth programs, including the Participant’s chosen program is available online at https://hsc.unm.edu/diversity/programs/community/expo.html. As Participant’s parent or legal guardian, I understand and acknowledge that certain risks are inherent to participating in recreational activities and youth camps, due to one’s own actions, the actions of others or a combination of both. These risks may result in illness, injury, minor or serious, as well as damage to personal property. If I have any specific questions about Participant’s safety or the risks associated with Participant’s chosen camp, I understand that I should speak to the UNM HSC Office for Diversity, Equity and Inclusion – Communities to Careers Programs staff. In the event of an emergency, I authorize the University of New Mexico (“UNM”) and its agents or representatives to make arrangements as reasonably necessary to ensure my child’s welfare. In the event of an emergency, permission is granted to UNM to authorize emergency transportation, emergency medical care and/or treatments and hospital care for the minor. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. Knowing the risks and in consideration of being permitted to participate in the above named camp, I do agree to assume all risks of illness, personal injury or loss, bodily injury (including death), damage to or loss of, or destruction of any personal property resulting from or arising out of my child’s participation in the youth camp. I also, hereby release, waive, indemnify, hold harmless and discharge UNM, its Board of Regents, its officers, employees or agents, from any and all claims, damages, and injuries arising out of my child’s activities, including the use of equipment and facilities provided by UNM. I further understand that UNM does not provide health insurance for individuals participating in youth camps. As such, either I or my personal health insurance will be responsible for payment of medical services and care for any injuries sustained during the youth camp. By signing this form, I am stating that I have read this waiver and notice of risk, fully understand its terms and understand that it affects my legal rights and how it affects those legal rights. I am signing this waiver and notice of risk knowingly and voluntarily, and intend for it to be a complete and unconditional release of liability to the greatest extent of the law.

Parent/Guardian please type your name (by typing your name you acknowledge our terms and consent to the above).

Send me a copy of my responses

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