Spring 2018 "Take A Look" Registration Form

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* 1. Please provide your contact information below.

Name (First & Last) *

Address *

Address 2 *

City/Town *

State/Province *

ZIP/Postal Code *

Country

Email Address *

Phone Number *

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* 2. Program or School

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* 3. Resident/Fellow/Medical Student/Allied Health Professional Status

Medical Student

PGY-1

PGY-2

PGY-3

Fellow

Nurse Practitioner

Physician Assistant

Other

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* 4. Specialty/Subspeciality (i.e., Internal Medicine, Family Medicine, Cardiology, Psychiatry)

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* 5. My Program/Clerkship Director is aware that I will be participating in the "Take A Look" Tour and I have been granted time off.

Yes, I have been granted permission.

No, I am working on it.

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* 6. Will you be bringing your spouse?

Yes, I will be bringing my spouse.

No, I will not be bringing my spouse.

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* 7. If yes, what is your spouse's full name?

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* 8. Would s/he be seeking employment in healthcare?

Yes

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* 9. What do you hope to learn from the "Take a Look" Tour?

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* 10. What are your career interests?

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* 11. Were you raised in New York? If not, please indicate where you are from in the 'Other' field.

Yes

Other (please specify)

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* 12. How did you hear about the "Take A Look" program?

Other (please specify)