NEW HOST (eHOST) Request Form - Student

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* 1. Student Registration Information:

First Name:

Last Name:

Student ID:

RUSM E-mail:

Preferred Phone:

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* 2. Please list the residency program you will be interviewing at along with the specialty and date of interview using the format below.

ex. University of Miami/City, State/Internal Medicine/01-24-2021

PLEASE NOTE: Please only complete a request for the participating programs/locations currently listed on the interactive map on the eHOST website. If a location is not listed please send an email to RUSMAlumni@rossu.edu.

Program #1:

Program #2:

Program #3:

Program #4:

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* 3. Please tell us a little about yourself. We’ll share your bio with your eHOST(s).

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* 4. By registering for eHOST, I agree to be responsible for contacting the alum I am connected with. If I have any issues getting in touch with them, or have decided for any reason to cancel my request, I will notify the Alumni Relations office.*

I agree

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* 5. In addition to checking the box above, please type your full name in the space below to indicate that you have read the statement.*