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FAQ For Volunteers
Volunteer Evaluation
Registration – Host Volunteer
Please fill out this form if you would like to be a host and the MAA will contact you about student requests for your area.
First Name
*
Last Name
*
Class Year
What is your medical specialty?
Home Street Address
*
City
*
State
*
Zip Code
*
Email
*
Preferred Phone Number
*
Preferred Phone Type
*
Cell
Home
Secondary Phone Number
Secondary Phone Type
Cell
Home
Pager
Other
Preferred Contact Time
*
Morning
Afternoon
Evening
Gender
*
Male
Female
Student Gender
*
Male
Female
No Preference
I am willing to provide
*
Lodging for a student
Transportation during visit
Information about residency programs
Lodging for a student and their significant other
Training hospitals in your area
*
Please provide full names and approximate commuting times from your home ex. University of Virginia Medical Center - 15 minutes; Martha Jefferson Hospital - 20 minutes
At what hospital did you receive your residency training?
Please provide full name of hospital
Where was this hospital located?
City, State
When did you complete your residency?
Year
Where are you currently employed?
Hospital or practice name and location
What is your current position title?
Travel plans
*
If you will be traveling during the months of October through January (Holiday, Clinical, Rotations, etc.), please provide approximate dates of travel and the best way to reach you during these periods:
Do you have any pets
*
Yes
No
If so, what kind
Additional Comments
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