GAIT 9/23/21

Geriatric Assessment Interdisciplinary Team (GAIT)

Participant Information Form

Virtual GAIT Project

Blackboard site opens for Independent Work Friday, Sept 17

Required Group Activity: Thurs, Sep 23; 08:30am-12:30pm

Falls Later in Life: Risk Assessment, Prevention, and Management

Name

Street Address

City

State

Postal / Zip Code

Please select

If "Other" selected above please specify, or type in N/A

Cell / Work Phone Number

University Email Address

Permanent Email Address

University Attending

Please select

Current Educational Level

Undergraduate- Year 1

Undergraduate- Year 2

Undergraduate- Year 3

Undergraduate- Year 4

Graduate- Year 1

Graduate- Year 2

Graduate- Year 3

Graduate- Year 4

Residency- Year 1

Fellowship- Year 1

Other

ESAHEC is required to report information about program participants. Data will be kept private to the extent allowed by law and will be referenced periodically to evaluate the effectiveness of ESAHEC services and programs. We appreciate your cooperation in the completion of this form.

Have you previously participated with an Eastern Shore Area Health Education Center program? (ex. GAIT, Continuing Education, Clinical Rotation)

Yes

Gender

Man

Woman

Non-Binary

Prefer not to disclose

Birth date

YYYY

Ethnicity

Hispanic

Non hispanic

Prefer not to disclose

Race

African American/Black

Native Hawaiian/Other Pacific Islander

American Indian/Alaskan Native

White

Asian

More than one race

Veteran Status

Veteran- Prior Service

Not a Veteran

Reservist

Veteran- Retired

Active Duty Military

Prefer not to answer

Do any of the below describe you/your background? 1) You have or currently receive Scholarship or Loan for Disadvantaged Students. 2) While growing up, you or your family ever used federal or state assistance programs. 3) While growing up, you lived where there were few medical providers at a convenient distance.

Yes

Are you a first generation college student?

Yes

In which kind of community did you grow up?

Medically Underserved

Rural

Urban

Suburban

Enrollment Status

Full Time

Part Time

Anticipated Date of Graduation

YYYY

In the box below please type in the name of the professor and his/her contact information that directed you to this event.

By checking of the box below, it is saying that you acknowledge that by registering for this GAIT event, that there will be ~4-5 hours of Blackboard work that MUST be completed prior to the event's date. Acknowledgment that participation in GAIT would take 8-9 hours

Yes, I understand.

By checking of the box below, you hereby voluntarily consent to and authorize the taking of photographs, videotapes or audiotapes of me and/or my family and the reproduction, transmission, publication or exhibition of these by the Eastern Shore Area Health Education Center (ESAHEC).

Yes, I understand.

By typing my name here, I am signing this document electronically and I certify that I am 18 years of age or older. (If you are under 18 years of age, a parent or legal guardian must sign)

You will receive confirmation and additional materials within 5 days. Please contact Pam Allen via email at: pallen@esahec.org if you have any questions or do not receive confirmation and additional materials.

Verification