2016 KEYSTONE GAMES MEDICAL STAFF INFORMATION FORM
Please fill out the form below
Last Name
Your answer
First Name
Your answer
Sex
Street Address
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Business Phone
Format (555)- 555-5555
Your answer
Home Phone
Format (555)- 555-5555
Your answer
Cell Phone
Format (555)- 555-5555
Your answer
Email
Your Information will be kept confidential
Your answer
I will be arriving at KSG as a volunteer on
I will be leaving:
I will be leaving:
My Comfort level with covering events is:
Note: Event assignment occurs daily by medical command based on available personnel and number/type of sports
Please Check One (if applicable)
Please send a copy of current certificate with this form or bring it with you to the games.
Based on the previous question please give more information if you have selected Resident, Fellow, Attending Physician, or Other (Residents please list your program and PGY level)
Please indicate PGY Level for Resident - - Program for Fellow -- Attending Physician SM CAQ - - Or any other information needed.
Your answer
I am interested in attending:
I need HOUSING for:
Please indicate arrival and departure time
I am not availabe for this year's KSG
Submit
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