Resident Advocacy Program Reply Form

Question Title

* 1. Our program will participate in the Resident Advocacy Program.

Yes

No

Other (please specify)

Question Title

* 2. VERIFY INFORMATION: (Please complete in full)

RESIDENT PROGRAM DIRECTOR NAME:

COORDINATOR NAME:

HOSPITAL:

ADDRESS:

CITY/STATE/ZIP:

PHONE:

FAX:

PREFERRED EMAIL:

Question Title

* 3. Resident Participant

NAME :

PGY:

PHONE:

EMAIL:

Question Title

* 4. Resident Participant

NAME :

PGY:

PHONE:

EMAIL:

For additional information please contact Katie Gordon at kgordon@ny.acog.org or 518-436-3461.