Membership Application Member Application Type of Membership Academic Member: A faculty or academic non-faculty member of any college of Cornell University. Affiliate Member: A faculty member of other organizations affiliated with Cornell University and its colleges. Community Member: A member of the Center’s Community Advisory Board and other community partners. Student/Trainee/Staff Member: A student, trainee or staff of any college of Cornell University and its colleges or affiliated organizations. Member Type * Academic Member Affiliate Member Community Member Student/Trainee/Staff Member Basic Demographics First Name * Middle Initial Last Name * Degree Title * Organization College/School Weill Cornell Medicine Weill Cornell Medicine-Qatar Weill Cornell Graduate School of Medicine Sciences College of Agriculture and Life Sciences College of Architecture, Art and Planning College of Arts and Sciences Cornell SC Johnson College of Business College of Engineering College of Human Ecology School of Industrial and Labor Relations Faculty of Computing and Information Science Cornell Tech Cornell Law School College of Veterinary Medicine Cornell Cooperative Extension Department Area of Expertise (Methods) * Area of Expertise (Content) * Mailing Address * Mailing Address Address 1 Address 1 Address 2 Address 2 City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Phone * Email * Create a password that you can use to log in and edit your listing after your application has been approved. Password * Confirm Password * Confirm Password Administrative Assistant First Name Last Name Phone Email Upload Documents / Photo Documents Drop a file here or click to upload Choose File Maximum upload size: 3MB Resume, 5-page NIH-format Biosketch or NSF Biosketch High resolution headshot Drop an image here or click to upload Choose File Maximum upload size: 4MB Upload a photo Signature Signature (draw or type) * Clear Date * Cornell Center for Health Equity Programs Please review the design, structure, and functions of the Center on our websites by clicking on this link Cornell Center for Health Equity organizational-structure. Members are expected to fulfill the Affiliation Criteria (page 1) for their center affiliation. Members are welcome and encouraged to attend meetings and events of interest to them. Information regarding research at the Center can be found on our website by clicking this link Cornell Center for Health Equity Research. Area of interest (select all that apply) * Community Engagement and Dissemination Investigator Development/Mentorship Education Center Membership (select all that apply) Currently hold a CCHEq leadership position Researcher involved in health equity Clinician involved in health equity patient care Educator involved in diversity or health equity Community organization interested in collaborative research Center Membership (select all that apply) Researcher involved in health equity Research and/or Interest - Expertise, Experience and Goals Please highlight your area of research or focus in general and how it relates to your interest in the Center. (Note: This paragraph will be posted on the website next to your photo along with your email address.) Research Interest * How does your professional expertise and experience benefit the Center and what do you hope to get out of your membership (e.g., network, collaborations, education) Expertise, Experience and Goals * reCAPTCHA If you are human, leave this field blank. Apply
