HOST Student Registration | UVA Medical Alumni Association & Medical School Foundation

First Name*

Last Name*

Alumni Host Gender*

Male
Female
No Preference

I'm looking for a host to provide the following*

Please note, this is preference. All options may not be provided. We will do our best to provide a host who is able to provide as many of the requested services as possible. **

Preferred Contact Time*

Morning
Afternoon
Evening

Email*

Preferred Phone Number*

Preferred Phone Type*

Cell
Home

Secondary Phone Number

Secondary Phone Type

Cell
Home
Pager
Other

Additional Comments

Special needs, allergies to household pets, etc.

Where are you interviewing*

Provide Full Name of Medical Center #1

Medical Center #1 Location

City, State

Street Address*

Interview Date at Medical Center #1*

What evening(s) will you require lodging in this area?*

During my visit, I plan to:*

Drive my own car
Rent a car
Utilize public transportation
Other

If Other, please specify

What is the specialty for which you are interviewing?*

Will your spouse or significant other accompany you?*

Yes
No
Maybe

Where are you interviewing

Provide Full Name of Medical Center #2

Medical Center #2 Location

City, State

Street Address

Interview Date at Medical Center #2

What evening(s) will you require lodging in this area?

During my visit, I plan to:

Drive my own car
Rent a car
Utilize public transportation
Other

What is the specialty for which you are interviewing?

Will your spouse or significant other accompany you?

Yes
No
Maybe

Where are you interviewing

Provide Full Name of Medical Center #3

Medical Center #3 Location

City, State

Street Address

Interview Date at Medical Center #3

What evening(s) will you require lodging in this area?

During my visit, I plan to:

Drive my own car
Rent a car
Utilize public transportation
Other

If other, please specify

What is the specialty for which you are interviewing?

Will your spouse or significant other accompany you?

Yes
No
Maybe