UNMC

Child Health Research Institute (CHRI) Membership Form

Application for new members

Select information from this application will appear in your CHRI Member Profile on our public webpage

Today's Date: 01/31/2023

*Required Fields

Last Name:*
First Name:*
Middle Initial:
Title:*
Credentials:*
Campus/Office Address:*
City:
State:
Zip:
Phone:
Fax:
Email:*
Relevant Professional Social Media Links:
Please select by rank the top 3 area(s) of emphasis most closely align with your research interests:
(only one area is required, ranking others is optional):
Please provide a brief description of your pediatric research interests and/or current research summary:*
Please provide a few keywords that describe your pediatric research interests:*
Please list your active collaborations with other UNMC / CHMC / CHRI:*

If you have any questions, please contact: Jaclyn Ostronic: jaclyn.ostronic@unmc.edu
Type the text from the image into the space below.
Form last updated 1/18/23

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