Take A Look Registration

Name *

First

Last

Email *

Mobile Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please indicate your title below by choosing ONE of the following options. *

If you answered OTHER ALLIED HEALTH PROFESSIONAL, please specify below.

What are you career interests? (i.e. internal medicine, family medicine, cardiology, psychiatry, unknown) *

Were you raised in New York? *

If you answered YES to the above question, please indicate where in New York you were raised.

If you answered NO to the above question, please indicate where you were raised.

What do you hope to learn from the "Take A Look" Tour? *

Do you have any food restrictions and/or allergies? *

If you answered YES to the above question, please indicate your food restrictions and/or allergies below.

Please indicate your shirt size. *

Please list an Emergency Contact (name and telephone number). *

My Program/Program Director is aware I will participating in the "Take A Look" tour and I have been granted time off. *

I understand I must arrive in Clifton Park, NY no later than 12:00pm on Wednesday, October 23. *

How did you hear about the "Take A Look" program? *

If you answered OTHER, please specify below.