Registration (Leadership and Academic Medicine Conference) 2019 Leadership and Academic Medicine Conference Registration Type*COLLEGE STUDENT/POST-BACC (copy of valid ID or letter required) $30MEDICAL/PhD STUDENT (copy of valid ID or letter required) $30RESIDENT (copy of valid ID or letter required) $50FELLOW/FACULTY/OTHER $100Speaker (Free)Location (select one):*UC Davis School of Medicine, February 1-2, 2019Scan of ID/LetterIf necessary, please upload a scan of your valid ID or another official letter which designates your status.Accepted file types: pdf.Will pay later?YesWho will be paying for you?*For medical students, residents and fellows: Would you like to meet with a residency recruiter or faculty recruiter to discuss opportunities at their institution?YesNoIf yes, which specialty are you considering or currently practicing?Name* First Last Email* BNGAP username*If you have not yet registered for BNGAP.org, please write "Not registered"Position/Title*Institution*Street Address*City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificOtherZip Code*CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwePhone*Race/Ethnicity* White Asian Native American/Alaskan Native Hispanic/Latino Black/African-American Prefer not to answer Other Specify if OtherBirth sex*MaleFemaleIntersexOtherPrefer not to answerSpecify if OtherSexual Orientation*Straight or heterosexualGay or lesbianBisexualOtherPrefer not to answerSpecify if OtherGender Identity*Female/WomanMale/ManTransfemale/TranswomanTransmale/TransmanGenderqueer/Gender nonconformingOtherPrefer not to answerSpecify if Other We are working with host institution leaders to try and identify trainees who are willing to host out-of-town participants conference participants.If applicable (your institution is hosting), are you willing to host an out-of-town participant?YesNoCriteria for hostingDo you have any specific criteria for hosting (male or female, etc)?If applicable (you are coming from another institution), would you like to receive information on staying with a host trainee or faculty member?YesNoWould you be willing and interested to carpool to the sites with other participants?YesNoYour total registration feePlease press submit to continue to Paypal to complete your registration. $0.00 NameThis field is for validation purposes and should be left unchanged.