NEW Host (eHost) Registration Form - Alumni

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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)

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* 3. Please indicate any date(s) that you will not be available to host students (excluding holidays).

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* 4. 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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* 5. Are you willing to speak to students about your specialty, regardless of residency location?*

Yes

n/a

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* 6. Which programs or teaching hospitals do you feel comfortable answering questions about? (other programs you may know of)

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

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* 8. Please tell us a bit about yourself and your city that will be beneficial in the student matching process! Anything from your career path to your hobbies to your favorite local restaurant is appreciated. We will share this information with the students you offer to connect with.*

*NEW* Host (eHost) Registration Form - Alumni

Question Title

* 1. Alumni Registration Information:

Question Title

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

Question Title

* 3. Please indicate any date(s) that you will not be available to host students (excluding holidays).

Question Title

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

Question Title

* 5. Are you willing to speak to students about your specialty, regardless of residency location?*

Question Title

* 6. Which programs or teaching hospitals do you feel comfortable answering questions about? (other programs you may know of)

Question Title

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

Question Title

* 8. Please tell us a bit about yourself and your city that will be beneficial in the student matching process! Anything from your career path to your hobbies to your favorite local restaurant is appreciated. We will share this information with the students you offer to connect with.*

NEW Host (eHost) Registration Form - Alumni