PREFAC Seminar Academic Medicine Career Development

Please complete the following form to register for the PREFAC Seminar – Academic Medicine Career Development. If you select a payment option, you will be prompted to pay via Paypal.

PLEASE REGISTER EARLY. Registration for each conference site will close 3 days prior to the start of the conference. Individuals who would still like to register must do so at the conference.
For medical students and residents, a copy of an ID or letter (confirming your educational status) is required to register. If you’d like to register before providing a scanned copy of either, please bring an ID or letter to the conference.
If you’d like to pay later or as part of a group, please select the “Will pay later” option and indicate who will be paying for you.
Registration Refunds are provided if we are contacted 72 hours before the start of the conference.

PREFAC Seminar Academic Medicine Career Development Registration

Registration Type*
- COLLEGE STUDENT/POST-BACC
- MEDICAL/PhD STUDENT
- RESIDENT
- FELLOW
- OTHER
- SPEAKER/FACILITATOR
Decribe Registration Type 'Other'
Please describe 'Other'? (e.g. dental student, nursing student, staff, faculty member, etc.)
If participant, how INTERESTED are you in a career in academic medicine?*
- Very interested
- Interested
- Neither interested nor disinterested
- Disinterested
- Very disinterested
- N/A - speaker
Location (select one):*
- Unified/Regional BNGAP Seminar - March 11th, 2023
Will pay later? (Please mark Yes, if you are being sponsored by your or another school and then place your school's name in the section for 'Who will be paying for you'. The seminar at New York Medical College is FREE for all.)
- Yes
Who 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?
- Yes
- No
If 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*
Zip Code*
Country
Phone*
Race/Ethnicity*
- White
- Asian
- Native American/Alaskan Native
- Hispanic/Latino
- Black/African-American
- Prefer not to answer
- Other
Specify if Other
Birth sex*
Specify if Other
Sexual Orientation*
Specify if Other
Gender Identity*
Specify if Other
Will you be attending in person or virtually?*
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?
- Yes
- No
- Not Applicable
Criteria for hosting
Do 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?
- Yes
- No
- Not Applicable
Would you be willing and interested to carpool to the sites with other participants?
- Yes
- No
- Not Applicable
Your total registration fee
Please press submit to continue to Paypal to complete your registration.
$0.00
Name
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