2016 Resident Advocacy Program Registration

Question Title

* 1. Contact Information: (Please complete in full)

HOSPITAL/PROGRAM:

PROGRAM DIRECTOR NAME:

PROGRAM DIRECTOR EMAIL:

COORDINATOR NAME:

COORDINATOR EMAIL:

PHONE:

ADDRESS:

CITY/STATE/ZIP:

Question Title

* 2. Resident #1 Contact Information....

Name:

PYG:

Address:

City:

ZIP:

Email Address:

Phone Number:

Question Title

* 3. Resident #2 Contact Information...

Name:

PYG:

Address:

City:

ZIP:

Email Address:

Phone Number:

Thank you for applying to the Resident Advocacy Program. We will contact you shortly to select dates of participation and finalize your application. Should you have questions or need additional information please contact Katie Gordon at kgordon@ny.acog.org or 518-436-3461.