Public Health Influencer Summer Institute – Deep South Center for Occupational Health & Safety

Public Health Summer Program

Full Name *

High School *

Address *

Which grade will you be in Fall of 2024? *

GPA (If unknown, please put N/A)

State *

Zip Code *

Phone *

Student Email *

Parent Email

Why are you interested in the program? (250 words or less)

Once you learn more about public health, how do you plan to be a public health influencer in your social network? (250 words or less)

Have you ever attended a course in your HS focused on health?

Yes

What was the class subject or topic focus?

Emergency Contact Information (Full Name)

Phone

Relationship to you (Parent, Grandparent, Guardian, etc.)

If you are human, leave this field blank.

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.