2018 Resident Advocacy Program Registration - May 21 & 22nd

2018 Resident Advocacy Program Registration

This registration is for the May 21 & 22nd Residency Advocacy Program and Lobby Day.

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:

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

Name:

PYG:

Home Address:

City:

ZIP:

Email Address:

Phone Number:

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* 3. What is your gender? (used for hotel purposes)

Female

Male

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* 4. Resident #2 Contact Information...

Name:

PYG:

Address:

City:

ZIP:

Email Address:

Phone Number:

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* 5. What is your gender? (used for hotel purposes)

Female

Male

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* 6. Hotel Accommodations Needed?
We will contact residents after receiving their registration regarding hotel stay.

Yes

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* 7. Do you have any dietary restrictions?

Thank you for applying to the Resident Advocacy Program. We will contact you shortly to finalize your application. Should you have questions or need additional information please contact Ericka Hancox at ehancox@ny.acog.org or 518-436-3461, ext. 501.

Question Title

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

Question Title

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

Question Title

* 3. What is your gender? (used for hotel purposes)

Question Title

* 4. Resident #2 Contact Information...

Question Title

* 5. What is your gender? (used for hotel purposes)

Question Title

* 6. Hotel Accommodations Needed?We will contact residents after receiving their registration regarding hotel stay.

Question Title

* 7. Do you have any dietary restrictions?

* 6. Hotel Accommodations Needed?
We will contact residents after receiving their registration regarding hotel stay.