Changing Faces Form - The Dr. Samuel D. Harris National Museum of Dentistry

Biographical Background

Name(Required)

Prefix First Middle Last Suffix

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email(Required)

Your address, phone, and email will only be used to contact you regarding your submission and any potential updates to your story. It will not be made public.

Race and/or Ethnicity(Required)

Select all that apply

Consent for Public Use of Race and/or Ethnicity Data(Required)

I consent to this information being made public and searchable as part of the Changing Faces Exhibition

I consent to this information being utilized anonymously for research by the museum, but not to be made public

I do not consent to this information being made public or being used for research purposes by the museum

American Indian Nation

Please provide what nation you identify with

Other Racial and/or Ethnic Background

Please use this space to identify what racial and/or ethnic background you identify with that was not included on the list.

Gender Identity(Required)

Consent for Public Use of Gender Identity Data(Required)

I consent to this information being made public and searchable as part of the Changing Faces Exhibition

I consent to this information being utilized anonymously for research by the museum, but not to be made public

I do not consent to this information being made public or being used for research purposes by the museum

Other Gender Identity

Please use this space to identify what gender you identify with that was not included on the list.

Sexual Orientation(Required)

Asexual

Bisexual

Gay

Intersex

Straight

Lesbian

Queer/Questioning

I prefer not to answer

Consent for Public Use of Sexual Orientation Data(Required)

I consent to this information being made public and searchable as part of the Changing Faces Exhibition

I consent to this information being utilized anonymously for research by the museum, but not to be made public

I do not consent to this information being made public or being used for research purposes by the museum

Religious Affiliation(Required)

Buddhist

Christian

Hindu

Jewish

Muslim

Unaffiliated

Other

Consent for Public Use of Religious Affiliation Data(Required)

I consent to this information being made public and searchable as part of the Changing Faces Exhibition

I consent to this information being utilized anonymously for research by the museum, but not to be made public

I do not consent to this information being made public or being used for research purposes by the museum

Other Religious Affiliation

Please use this space to identify what religious affiliation you identify with that was not included on the list.

Birth Date(Required)

This information will not be made publicly available, but will be used for internal research and data collection.

What was your relationship with oral health and dentistry growing up?

When did you become insterested in oral health and dentistry?(Required)

Educational Background

Degree Program(Required)

Institution(Required)

Graduation Year(Required)

Please enter a number from 1900 to 2030.

Have you attended more than one educational program?(Required)

Yes

No

Degree Program

Institution

Graduation Year

Please enter a number from 1900 to 2030.

Have you attended more than two educational programs?

Yes

No

Degree Progam

Institution

Graduation Year

Please enter a number from 1900 to 2030.

Have you attended more than three educational programs?

Yes

No

Education Program(s) Attended and Graduation Year(s)

Please provide any other educational programs you would like to include using the same format as above.

Advanced Training

Institution

Post Custom Field

Have you completed more than one advanced training?

Yes

No

Other Advanced Training

Please provide any other completed advanced training you would like to include using the same format as above.

Your Trailblazing Story

Are you currently practicing dentistry?(Required)

Yes

No

I've never practiced dentistry

Are you currently practicing full-time or part-time?

Full-time

Part-time

When did you stop practicing dentistry?

If the exact date is unknown, please enter the best approximation. If Month and Year are known, but day is not, please enter 1 for the day. If only the year is known, please enter 1 for the month and 1 for the day.

How is your career related to oral health and/or dentistry?

How would you describe your trailblazing story in 10 words or less?(Required)

What is your trailblazing story?(Required)

Please include an overview of the people, places, events, and time that are important to your trailblazing story.

Why did your trailblazing story happen?(Required)

Please include any motivation or other factors that lead to your trailblazing story happening.

Who is/are your dental role model(s) and mentor(s)?(Required)

Do you wish to provide any additional facts about your life story not otherwise requested?(Required)

Yes

No

Ex. family or cultural background, previous career, engagement in civic or entrepreneurial activities, sports, creative arts, etc.)

Additional facts about your life story:

Changing Faces Biographical Profile Submission Form

Biographical Background

Educational Background

Your Trailblazing Story

Images & Consent

NMD Group Tour Form

Group Information

Visitor Information

Scheduling Options