Natalie Sugira

"I must speak up, because so many of the women who survived the genocide are now dying of AIDS."

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Student Advocacy

Chapter Registration Form

Register your chapter for the 2008-2009 academic year to stay connected with the PHR Student Program. As a registered PHR student chapter, you will receive organizing and action tools, outreach materials, campaign and action updates and event invitations to help your chapter address some of the most serious health and human rights issues today.

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Chapter Information

Our chapter is*

an existing chapter

a new group

University/School*

Department/Division

Street Address*

Room/Suite/Floor

City*

State*

Postal Code*

School Type*
(control-click to
choose more
than one)

Send our

Chapter Coordinator's Address

mailings to

Faculty Advisor's Address

(check all that apply)

Other Chapter Member (see below)

Fall 2007-Spring 2008 Chapter Coordinator (Student)

First Name*

Last Name*

Field of Study*

Year of Graduation*

Name of Business/Dorm/Building

Street Address*

City*

Room/Suite/Floor

State*

Postal Code*

Address Location*

Preferred Phone*

Email*

Another Fall 2007-Spring 2008 Chapter Contact (non-graduating)

First Name

Last Name

Field of Study

Year of Graduation

Name of Business/Dorm/Building

Street Address*

Room/Suite/Floor

State

Postal Code

Address Location

Preferred Phone

Additional Fall 2007-Spring 2008 Chapter Contacts

First Name	Last Name	Chapter Position	Email	Phone

Faculty Advisor

Prefix

First Name

Last Name

Title

Department

Street Address

Room/Floor/Suite

City

State

Postal Code

Work Phone

Work FAX

Second Phone

Email:

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