Host (eHost) Registration Form

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* 1. Alumni Registration Information:

First Name

Last Name (at graduation)

Current Last Name: (if changed after graduation)

Class Year:

Preferred E-mail:

Preferred Phone:

Current Practice/Hospital Name:

Current Title: (resident, private practitioner, etc.)

Current Specialty:

City, State:

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* 2. As an eHOST ambassador, I am willing to provide the following: (select all that apply) - Other (please specify)

Information regarding a residency program

Sponsor a student's lunch (offer gift card)

Become student's mentor

Other (please specify)

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* 3. As an eHOST ambassador, I am willing to provide the following: (select all that apply) - Other (please specify)

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* 4. Please indicate any date(s) between October and January that you will not be available to host students (excluding holidays).

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* 5. How would you prefer to connect with students? (Check as many as you wish.*

Phone, at the number listed above

Text message, at the number listed above

Zoom, or other videoconferencing platform, set up by the student

Email, at the address listed above

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* 6. The total number of students I am willing/able to host at one time is:

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* 7. Please provide any additional information that will be beneficial in the student matching process.