Registration: Residency Interview CDI Receptions 2021 - 2022
*
1.
First Name:
(Required.)
*
2.
Last Name:
(Required.)
*
3.
Pronouns:
(Required.)
She/her/hers
He/him/his
They/them/theirs
Other (please specify)
*
4.
Email Address:
(Required.)
*
5.
Role/Title (choose one):
(Required.)
Applicant - Residency Program
Applicant - Fellowship Program
Current Faculty
Current Fellow
Current Resident
Administrative (Leadership, BRI, CCHHE, etc.)
Other (please specify)
*
6.
Department/Fellowship Program/Residency Program:
(Required.)
*
7.
Which reception(s) will you be attending?
*We are hosting two joint receptions with MGH CDI. If you have already registered for a joint reception through MGH CDI, you're all set!
(Required.)
Wednesday, October 27, 2021 (5-6pm EST)
Thursday, November 4, 2021 (6-7pm EST)
Thursday, November 18, 2021 (6-7pm EST) - *Joint reception with MGH CDI for combined programs
Wednesday, December 1, 2021 (5-6pm EST)
Tuesday, December 14, 2021 (6-7pm EST) - *Joint reception with MGH CDI for combined programs
Thursday, December 16, 2021 (6-7pm EST)
Wednesday, January 5, 2022 (5-6pm EST)
Monday, January 10, 2022 (12-1pm EST)
Tuesday, January 18, 2022 (6-7pm EST)
8.
Do you identify as any of the following? (response optional)
I am underrepresented in medicine (defined as American Indian, Alaskan Native, Black/African American, Hispanic/Latinx or Native Hawaiian)
I am LGBTQ
I have a disability
Current Progress,
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