Community Public Health and Scientific Faculty

2. I have been approved as a BVRC volunteer*

   1. Yes
   2. No

   If you are not a BVRC volunteer, please see the below steps on how to become one:

   • Go to maresponds.org and Click on "add organization". Pick "Region 4A" as the "region" and "Burlington Volunteer Reserve Corps" as the "unit affiliation".
   • Come to the Board of Health office to have your picture taken for an ID badge and to complete a CORI form.

   For hours or assistance, call the Board of Health at 781-270-1955.

4. What area is your presentation going to cover? Check all that apply.*

   1. Governmental
   2. Public Health
   3. Clinical
   4. Scientific Advances in the Community
6. Please describe your presentation:*
8. What is your expertise in relation to this topic?*
10. What is your experience or expertise with the subject matter you are going to cover in your presentation? This should only be filled in if it is not reflected on your CV/Resume.
12. Do you represent an organization?*

    1. Yes
    2. No
13. If yes, who do you represent for?
15. What is the length of your presentation:*

    1. 30 Minutes
    2. 45 Minutes
    3. 60 Minutes
17. Please upload/attach the following:
19. CV/Resume*
20. Organization(s) representing, if applicable.
21. Any commercial support or vested interest being presented for that organization, if applicable.
22. Presentation topic and copy of the presentation (limit to 45min with 15min Q&A) for review.*
24. PROFESSIONAL/ETHICAL CONDUCT*

    1. I agree to conduct myself in a professional manner and treat all participants with dignity and respect regardless of sexual orientation, gender identity or transgender status.
26. Signature of Applicant*

    This is an electronic signature to submit your application, there is no need to print or download this form for a physical signature.

27. Date*
    Date
29. If you have any questions or concerns, please contact the Board of Health at 781-270-1955 or email boh@burlington.org.
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit Submit and Print

* indicates a required field