Poverty Simulation Interest Form
**This event has reached capacity; you may fill the form out to be added to a wait list. You will be contacted should a spot open up**

By completing this form you are signing up to participate in the Community Action Poverty Simulation taking place at the IPE Center of Health Sciences North on Thursday, Dec. 2., at 5:30 p.m. If you wish to receive community service hours, you will receive an email with the iServe link once the form is submitted. *Now you will receive this link when contacted if a spot opens*

This questionnaire should take no more than three minutes to complete.

The simulation is co-hosted by members of the Reed College of Media, Schools of Public Health and Pharmacy, the HSC Office of Interprofessional Education and the STEPS Center.
Email *
Please write your full name: *
WVU student ID: *
How old are you? *
Preferred pronouns *
Where are you from? (Please include city, state and country, if not the United States) *
What is your race? *
Required
What is your ethnicity? *
Which college is your major/field of study affiliated with? *
What year are you? *
Which degree are you pursuing? *
What are your career aspirations? *
Are you a member of any student organizations? *
If yes, which ones, and what is your role (if applicable)?
Would you say your curriculum addresses possible social, economic or physical barriers patients/clients may experience? *
Have you ever participated in a simulation before? *
If yes, what was the simulation for?
Have you attended a University-affiliated event in the past year? *
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