TeleHealth Group Sign Up: Buy 5 Get 1 Free

** You do not have to be a student of the University listed, that is only where the chapter originates

Trip dates: April 5—June 30, 2021

Cost: $445

Spots remaining: 90

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Which program would you like to sign up for?*
- SOLD OUT -- April 5 - 30, 2021
- May 3 - 28, 2021
- June 1 - 29, 2021
Intern 1
First & Last name*
Email address*

Note: must be an email through which you can access Google Drive
Intern 2
First & Last name*
Email address*

Note: must be an email through which you can access Google Drive
Intern 3
First & Last name*
Email address*

Note: must be an email through which you can access Google Drive
Intern 4
First & Last name*
Email address*

Note: must be an email through which you can access Google Drive
Intern 5
First & Last name*
Email address*

Note: must be an email through which you can access Google Drive
Intern 6
First & Last name*
Email address*

Note: must be an email through which you can access Google Drive
Other Information
University(ies)
How did you find out about the VAW Global TeleHealth Program?*
- Facebook / Instagram
- WhatsApp or GroupMe text
- Google Search
- VAW Chapter Team Leader / TDC
- Other (please elaborate below)
Other

If you answered "other" to the prior question, please elaborate.
Who referred you to the VAW Global TeleHealth Program (if applicable)?*

Please note their full name, including first and last name, and university, if applicable.
Terms and Conditions*
- We have read and agree to the TeleHealth Terms and Conditions of VAW Global Health Alliances.
TeleHealth Intern Group Sign-Up
Payment Method*

MasterCard
Visa
Supported Credit Cards: MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

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