MAPS Registration MAPS Conference 2023 – Registration Form Minority Association of Pre-medical Students Conference Students interested in attending the M.A.P.S Conference may enter information to be contacted by the SNMA Maps Liaison. Today's Date MM slash DD slash YYYY Name(Required) First Middle Initial Last Nickname Race(Required)White/CaucasianBlack/African AmericanAmerican Indian or Alaska NativeAsianNative Hawaiian or Other Pacific IslanderMore than one raceOtherEthnicity(Required)Hispanic/LatinoNon-Hispanic/LatinoDate of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemaleOtherPrefer Not to SayMailing Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Is Permanant Address Same as Current Address?(Required)YesNoPhone(Required)School/College Email(Required) Permanent Email(Required) Hometown(Required) College/University(Required) Are you a MAPS Advisor, College Faculty, or Work with Prehealth Students?(Required)YesNoAre you a UAMS Student, Faculty, or Staff?(Required)YesNoAre you an Attendee/Advisor, Speaker, or Volunteer? (With a checkbox for selection)(Required)Attendee/AdvisorSpeakerVolunteerArkansas Region/County(Required)Select current region based on county.Central (Pulaski)East (Crittenden, St. Francis, Lee, Monroe, Phillips, Desha, Chico)North Central (Marion, Baxter, Fulton, Sharp, Izard, Independence, Cleburne, Stone, White, Van Buren, Searcy)Northeast (Clay, Greene, Mississippi, Craighead, Lawrence, Randolph, Jackson, Cross, Woodruff)Northwest (Benton, Carroll, Boone, Newton, Madison, Washington)South (Columbia, Ouachita, Calhoun, Bradley, Union, Ashley, Dallas,)South Central (Prarie, Lonoke, Arkansas, Jefferson, Lincoln, Drew, Cleveland, Grant, Saline, Hot Spring, Garland)Southwest (Miller, Little River, Lafayette, Nevada, Hempstead, Clark, Pike, Howard, Sevier, Bowie, TX, Cass, TX)West (Crawford, Franklin, Johnson, Pope, Conway, Faulkner, Perry, Yell, Montgomery, Polk, Scott, Logan, Sebastian)From Disadvantaged Background?(Required)Select “YES” if any of the below apply -1st Generation to attend college -From high school with low SAT/ACT Scores or below the average state test results (School’s numbers) -From school district where 50% or less of graduates go to college -Diagnosed physical/mental impairment that substantially limits participation in education experiences – English is not primary language and language is still a barrier to academic performanceYesNoUnsureN/AMedically Underserved Community?(Required)YesNoUnsureN/AThere is a shortage of physicians per the number of people in your communityFrom Rural or Urban Area?(Required)YesNoN/AUnderrepresented Minority?(Required)YesNoN/AClassifications(Required)FreshmanSophomoreJuniorSeniorAnticipated Major(Required) Career Aspiration (Medicine, Pharmacy, Physician Assistant, etc.)(Required) Expected Graduation Date(Required) MM slash DD slash YYYY MAPS Conference-Breakout Sessions (Please Select 3) Gap Year-Medical Scholars in Public Health Post-Baccalaureate Program College of Medicine Admissions Interviewing Tips College of Pharmacy College of Public Health College of Health Professions – Physician Assistant Program College of Health Professions – Physical Therapy Program Graduate School – Research & Medicine Black Men in Medicine MAPS Advisors Informational “College of Nursing – Certified Registered Nurse Anesthetist Program Clinical Research Careers