The code block below illustrates how one might use # and // as comments in your logic and calculations.

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This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

BLaZNbkRRqkpxae2ZJUw4XBQbGy3yRawMWiEMBTLH6eXcBYbPLHGT

CIRCLE Membership Form

Please complete the survey below to sign up as a member of the CIRCLE program.

Thank you!

I'm interested participating in CIRCLE as a:

* must provide value

Researcher

Clinician

Student/trainee

Community member

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Please describe your interest in indigenous health and/or maternal morbidity and mortality so that we can best understand how our center can better serve your interests and involve you in our programs.

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First Name

* must provide value

Middle Name (or initial)

Last Name

* must provide value

Credentials

* must provide value

ORCiD (if known)

NIH Biosketch of curriculum vitae

* must provide value

Upload file

Primary Affiliation

* must provide value

Primary Affiliation (Other)

* must provide value

Primary place of practice

* must provide value

Speciality

* must provide value

Current educational institution

* must provide value

Current degree or training program

* must provide value

Community Organization (if applicable)

Address 1

* must provide value

Address 2

City

* must provide value

State

* must provide value

Zip code

* must provide value

Primary Phone

Alternate phone

e-mail address

* must provide value

Would you be interested in serving in advisory or focus groups if the opportunity arises?

* must provide value

Yes

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What is your gender?

How do you self-describe your gender?

What is your race? (check all that apply)

American Indian or Alaska Native

Black or African-American

Asian

Native Hawaiian or Other Pacific Islander

White

Some other race

Prefer not to answer

What tribal nations are you a member, citizen, or affiliated with?

What other race do you self identify as?

Are you of Hispanic, Latino, or Spanish origin?

Yes

Prefer not to answer

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What is the highest level of education that you have received?

Have never gone to school

5th grade or less

6th to 8th grade

9th to 12th grade

High school graduate or GED

Some college level/technical/vocational degree

Bachelor's degree

Other advance degree (non clinical)

Other advanced clinical degree\

Prefer not to answer

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