Registration – Host Student – UVA Medical Alumni Association

First Name*

Last Name*

Host Gender*

Male
Female
No Preference

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

Lodging during residency interviews
Transportation to interview
Information about residency program

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

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

Medical Center Location

City, State

Street Address*

Interview Date*

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

What is the specialty for which you are interviewing?*

Will your spouse or significant other accompany you?*

Yes
No
Maybe

During my visit, I plan to:*

Drive my own car
Rent a car
Utilize public transportation
Other

If Other, please specify

Resources For...

Students

Alumni

Housestaff

Faculty

Students

Registration – Host Student