Medical Development

HOST Student Registration Form

Simply complete the following HOST Registration electronic form, and let us know when and where you will be traveling.

The Office of Alumni Relations will then contact alumni in the requested area and find an available host for your specified time frame. We will match you with alumni first by geographic request and second by specialty.

Once a host is identified and notified of the match, we will then share contact information with you. It is up to you to call your host and share the details of your travel and interview arrangements.

After you return from your interview, we ask that you send a thank-you note to the host alumnus/a expressing your gratitude for their hospitality.

Please complete this form for each separate HOST travel request.

Personal Information:

E-mail Address

Preferred Title

First Name

Middle Name

Last Name

Home Phone

Cell Phone or Pager

Preferred time to reach you during the day

If you will be traveling during the months of November-February (holiday, clinical rotations, other residency interviews, etc.), please provide approximate dates of travel and the suggested way to reach you during these periods:

Campus Address :

Street Address

City

State

Zip Code

Travel Log:

(please complete the following for each travel destination for which housing is requested)

Specialty for which you are interviewing?

Medical Center/Residency Program:

Where is it located?

City

State

Zip Code

What are your dates in HOST interview city?

Arrival (mm/dd/yy)

Departure (mm/dd/yy)

What date(s) will you need overnight lodging? (mm/dd/yy)

Date of Interview (mm/dd/yy):

Will your spouse/significant other be accompanying you? (not all hosts are able to accommodate)

	Yes
	No
	If possible

Any other comments you wish to add (special needs - i.e. smoking preference, allergies to household pets, etc.):