Registration – Host Volunteer – UVA Medical Alumni Association

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

Resources For...

Students

Alumni

Housestaff

Faculty

Students

Registration – Host Volunteer