UNMC Delegates Enrollment Form

Please note that all communication with the UNMC Delegates will be electronic. We are requesting your home address to determine your state and federal Congressional district and respective representatives. The information you provide will be used solely in conjunction with the UNMC Delegates program and will not be released to outside sources. This is a secure form, as designated by the SSL icon (padlock) in the lower right or left corner of your browser.

*Required fields

Last Name: * First Name:

Profession: *

Position Title (optional):

Email: *

Home Mailing Address: *

City: * State: * Zip: *

Cell Phone (optional):

UNMC Affiliation – Please check all that apply *

Faculty
Staff
Alumni
Student
Friend
Other:

Indicate your areas of interest - Please check all that apply *

Health care
Research
Education
State/Federal policy issues
State/Federal budget
Other:

If you reside in Nebraska, please list your state senator.

If you are unsure, you may leave blank or click here.

Please list any personal contacts you have in the U.S. Congress or the Nebraska state legislature whom you know well.

If a need arises, are you willing to personally contact those you listed above on issues important to UNMC?* Yes No

Upon clicking the "Submit" button, you will be asked to enter your email address to receive the Delegates electronic newsletter, which will be sent once a month. This is the primary way of communicating UNMC news and events to the Delegates and is the final step in registering for the program. If you choose not to receive the newsletter, you will not receive the necessary information to advocate on behalf of UNMC.

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