PREFAC Seminar Leadership and Academic Medicine

Registration Type*

COLLEGE STUDENT/POST-BACC (copy of valid ID or letter required) $0
MEDICAL/PhD STUDENT (copy of valid ID or letter required) $0
RESIDENT (copy of valid ID or letter required) $0
FELLOW/FACULTY/OTHER $0
Speaker (Free)

Location (select one):*

EVMS-BNGAP, September 23 (Saturday)

Scan of ID/Letter

If necessary, please upload a scan of your valid ID or another official letter which designates your status.

Accepted file types: pdf, Max. file size: 4 MB.

Will pay later.

(If you mark pay later, please indicate if the host site, your own institution, you yourself, or someone else will be covering your registration fee. Weill Cornell is sponsoring all participants at their site).

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
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Black/African-American
Prefer not to answer
Other

Specify if Other

Birth sex*

Specify if Other

Sexual Orientation*

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Gender Identity*

Specify 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?

Yes
No

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

Would you be willing and interested to carpool to the sites with other participants?

Yes
No

Your total registration fee

Please press submit to continue to Paypal to complete your registration.

$0.00

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