MAPS Registration

Today's Date

Name(Required)

First Middle Initial Last

Nickname

Race(Required)

Ethnicity(Required)

Date of Birth(Required)

Gender(Required)

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is Permanant Address Same as Current Address?(Required)

Phone(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)

Are you a UAMS Student, Faculty, or Staff?(Required)

Are you an Attendee/Advisor, Speaker, or Volunteer? (With a checkbox for selection)(Required)

Arkansas Region/County(Required)

Select current region based on county.

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 performance

Medically Underserved Community?(Required)

There is a shortage of physicians per the number of people in your community

From Rural or Urban Area?(Required)

Underrepresented Minority?(Required)

Classifications(Required)

Anticipated Major(Required)

Career Aspiration (Medicine, Pharmacy, Physician Assistant, etc.)(Required)

Expected Graduation Date(Required)

MAPS Conference-Breakout Sessions (Please Select 3)

MAPS Conference 2023 – Registration Form