Medical Student Bed and Board Application

Medical students, please complete the information below as thoroughly as possible. After you submit your application, you will be contacted by the Office of Advancement within 1-2 working days. Thank you for your interest in this program!


Name:

Class Year:

Address:

Address 2:

City, State Zip:

Daytime Phone:

This is a:

Email:


Please enter as much information as possible about your upcoming trips:

 

 

Trip 1 Tentative Date:

Trip 1 City and State:

Trip 1 Program or Hospital Name//Specialty:

Trip 2 Tentative Date:

Trip 2 City and State:

Trip 2 Program or Hospital Name//Specialty:

Trip 3 Tentative Date:

Trip 3 City and State:

Trip 3 Program or Hospital Name//Specialty:

Trip 4 Tentative Date:

Trip 4 City and State:

Trip 4 Program or Hospital Name//Specialty:

Please list any additional relevant information (distance you're willing to travel from alumni's home to the program you're visiting, any allergies, anyone else traveling with you, etc...):