THE BLACK BARBERSHOP HEALTH OUTREACH PROGRAM: BARBERSHOP FORM

INTERNSHIP APPLICATION

ALL FORMS :

Black Barbershop Health Outreach Internship Program / Application

Successful applicants will show evidence of academic achievement (a 2.8 or above grade point average on a 4.0 scale) and will demonstrate one or more of the following:

1. You or members of your family have been adversely affected by health disparities related to: a. systemic failures of the social or physical environment; or b. inequities in the U.S. health care system.

2. Live in a community or area that is adversely affected by health disparities. Such communities would include both urban and rural areas whose residents have low health status or who are underserved by the health care system.

3. Have experience working in programs that address health disparities. Such programs include local health departments, community health centers, inner city/rural hospitals or organizations that conduct research on or develop policy related to health disparities.

4. Have done previous academic work (e.g., taken courses, written papers or participated in research projects) related to health disparities.


	First Name : -----___ Last Name: ----------- Date of Birth: --------- Gender: - -- ------- --- --------- ----- ------- ---------- Phone : ------ -----___ Cell Phone #: ----___ Email : --------------- -- Street Address: ------- City: ------------ ----- --- State: -------------------- Zip: --- --- ----- ------ -- Address After 5/1/10: City After 5/1/10: --__ State After 5/1/10: --_ Zip After 5/1/10: -----_ Primary Ethnicity: ------------_ Secondary Ethnicity (If applicable): --------------------------------------------- If "Other," Please Describe Ethnicity: ------------------------------------------ Current College/University:--------------------------------------------------------- Undergraduate Year Level in Fall of 2010: -_ List Colls/Univs Attend, Dates & Cities:----------------------------------------- College Extracurricular Activities:-------------------------------------------------- Comments:------------------------------------------------------------------------------ Please check to join our mailing list: Lead Record Type

Black Barbershop Health Outreach Program
333 East Nutwood St, Suite C
Ingelwood, California USA 90301 Phone: 310-412-8009
Fax: 310-412-0171 www.blackbarbershop.org

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Black Barbershop Sign Up

Volunteer Sign Up

Internship Sign Up

Corporate Vendor Space Form

2010 Mens's Summit Registration Form

BARBERSHOP SIGN UP :

The Black Barbershop Health Outreach Program is looking for black owned barbershops to participate in our national screening effort to help educate African American men about the life threatening complications of diabetes and high blood pressure. Please click on the link below and we will contact you within 24 hours.click here to sign up

VOLUNTEER SIGN UP:

The Black Barbershop Health Outreach Program is looking for volunteers in all areas to assist the DAP Foundation national screening effort. We are seeking medical as well as non-medical volunteers. Please click on the link below and we will contact you within 24 hours.
Click here to sign up

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