Medical Student Symposium: Residency Program Form

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Contact Details

Name(Required)

First Last

Title/Honors(Required)

Institution(Required)

Email(Required)

Enter Email Confirm Email

Zoom Representative(Required)

First Last

Zoom Rep. Titles/Honors(Required)

Zoom Rep. email address(Required)

How did you hear about this event?

Residency Program Information

this information will be shared with attendees

Hospital/Institution(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Program Director, Name, Title/Honors(Required)

Assistant Program Director, Name, Title/Honors

Second Assistant Program Director, Name, Title/Honors

Program Coordinator Name

Program Coordinator Email Address

Total EM Residents in Program

Fellowships Associations with your Program

Hospital Capabilities (Primary Stroke Center, STEMI, etc) or key program highlights

Special Program Features/Offerings Prospective Residents Should Know:

Website

Facebook

Instagram

Twitter

Hospital/Program Photo

Max. file size: 128 MB.

Customized Informative Flier (2 page maximum)

Max. file size: 128 MB.

If the file is larger than 2 pages, only the first two pages will be what is made available to attendees.

Payment Details

Residency Program Registration

Price:

Number of tickets needed

Total

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Credit Card

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Credit Card

Cardholder Name

Card Details

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Contact Details

Residency Program Information

Payment Details

Credit Card

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