Student Registration Form

HOST Student Registration Form

Simply complete the following HOST Registration electronic form, and let us know when and where you will be traveling.

The Office of Student Affairs will then contact alumni in the requested area and find an available host for your specified time frame. We will match you with alumni first by geographic request and second by specialty.

Once a host is identified and notified of the match, we will then share contact information with you. It is up to you to call your host and share the details of your travel and interview arrangements.

After you return from your interview, we ask that you send a thank-you note to the host alumnus/a expressing your gratitude for their hospitality.

Please complete this form for each separate HOST travel request.

First Name:

Middle Name:

Last Name:

Preferred Phone Number:

Include area code, no hyphens

Cell Phone:

Include area code, no hyphens

E-mail:

Preferred time to reach you during the day:

BOTH

Street Address:

City:

State:

Zip Code:

please complete the following for each travel destination for which housing is requested

Specialty for which you are interviewing?:

Medical Center/Residency Program:

City, State and Zip Code:

Arrival (mm/dd/yy):

Departure (mm/dd/yy):

Date of Interview (mm/dd/yy):

Spouse/significant other:

Yes

If possible

Will your spouse/significant other be accompanying you? (not all hosts are able to accommodate)