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Registration | Pasifika Health Leaders Webinar | 28 July 2021 - 5pm
3.
REGISTRATION FORM
*
1.
Full name
(Required.)
*
2.
Email address (*required)
(Required.)
*
3.
Gender
(Required.)
Male
Female
Gender diverse
Specify
4.
Please specify your current occupation and place of work.
Current occupation (position title):
Name of organisation, company, place of work:
*
5.
What Pacific ethnicity do you identify with the most?
(Required.)
Samoan
Tongan
Cook Island Maori
Niuean
Tokelauan
Fijian
Tuvaluan
I-Kiribati
Solomon Islander
Tahitian
Papua New Guinean
Rotuman
Maori
NZ European
Other European
Asian
African
Middle Eastern
Other Pacific
6.
If you are a student, please confirm which university you attend.
The University of Auckland
The University of Otago
Other (please specify)
7.
Please specify your area of study and current year of study.
Area of study
Current year of study
*
8.
Please confirm your attendance online or in person at the following venues for the ‘Pasifika Health Leaders Webinar':
(Required.)
Auckland Hospital
Middlemore Hospital
Tauranga Hospital
Waikato Hospital
Taranaki Hospital
Wellington Hospital
Christchurch Hospital
Dunedin Hospital
Online
Other (please specify)
9.
Please note any dietary requirements:
*
10.
How did you hear about this Pasifika Medical Association event/seminar?
(Required.)
Through PMA membership emails
Through university network
Through hospital colleagues
On social media
Pasifika Medical Association website
Word of mouth
Other (please specify)
*
11.
Please join our Pasifika Medical Association membership network for free to get more Pacific health updates, news and events.
(Required.)
Yes please add me as a member of Pasifika Medical Association
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