HOST Program - Alumni Volunteer Registration Form
The HOST Program matches alumni across the country with fourth year medical students who are traveling to their residency interviews (typically October - January) or are on away rotations throughout the year. Please complete the registration form below. Thank you for participating!
First Name:
Your answer
Middle Name:
Your answer
Last Name:
Your answer
Address Line 1:
Your answer
Address Line 2:
Your answer
City:
Your answer
State:
Your answer
Zip:
Your answer
Cell Phone:
Your answer
Home Phone
Your answer
Business Phone:
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Email
Your answer
Specialty:
Your answer
Grad Year:
Your answer
Currently Employed At:
Your answer
My gender is:
I prefer to host a medical student of the following gender:
I am willing to provide the following accommodations to a fourth year USC School of Medicine medical student:
Please check all that apply.
Required
Additional comments or information:
Your answer
Please identify the training hospitals in your area and provide the average community time from your home to the hospital.
Hospital 1:
Your answer
Please identify the training hospitals in your area and provide the average community time from your home to the hospital.
Hospital 2 (if applicable):
Your answer
Please identify the training hospitals in your area and provide the average community time from your home to the hospital.
Hospital 3 (if applicable):
Your answer
Terms and Conditions of Participating in the HOST Program:
Please check next to each of the terms and conditions listed below. As a volunteer participating in the HOST Program at the University of South Carolina School of Medicine, we ask that you please follow these terms and conditions set forth by the Alumni Office:
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