Spring 2018 "Take A Look" Registration Form Question Title * 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 * OK Question Title * 2. Program or School OK Question Title * 3. Resident/Fellow/Medical Student/Allied Health Professional Status Medical Student PGY-1 PGY-2 PGY-3 Fellow Nurse Practitioner Physician Assistant Other OK Question Title * 4. Specialty/Subspeciality (i.e., Internal Medicine, Family Medicine, Cardiology, Psychiatry) OK Question Title * 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. OK Question Title * 6. Will you be bringing your spouse? Yes, I will be bringing my spouse. No, I will not be bringing my spouse. OK Question Title * 7. If yes, what is your spouse's full name? OK Question Title * 8. Would s/he be seeking employment in healthcare? Yes No OK Question Title * 9. What do you hope to learn from the "Take a Look" Tour? OK Question Title * 10. What are your career interests? OK Question Title * 11. Were you raised in New York? If not, please indicate where you are from in the 'Other' field. Yes No Other (please specify) OK Question Title * 12. How did you hear about the "Take A Look" program? Friend/Family Member/Colleague/Program Director Facebook/Social Media Internet Search Flyer Other (please specify) OK DONE