Register for the Annual Boston Pre-Intern Orientation Community Organizing Workshop Full Name * First Name Last Name What do you prefer to be called? Email address (preferably non-institutional email like a Gmail address) * Phone Number * (this will be used by your small group coach to contact you with more information 1-2 weeks prior to the workshop) Academic Medical Center * i.e. MGH Residency Program * i.e. Internal Medicine What year of residency will you be starting in June 2022? * Intern PGY-2 PGY-3 Other If you entered "other", please describe here If not, leave blank Can you make a firm commitment to attend the entire workshop on Sunday, June 5th from 9AM-4:30PM EST? Please note that, due to the interactive nature of the workshop, we will not be able to have participants arrive late, leave early or join for only part of the day. * Yes, I can commit to attending the entire session on Sunday, June 5th For the purpose of ensuring that there are diverse perspectives in our small groups, please share the following information if you are comfortable. How would you best describe yourself? Feel free to choose multiple options or leave blank if you prefer not to answer. American Indian or Alaska Native Asian Black or African American Hispanic, Latino/a/x, or of Spanish origin Native Hawaiian or Other Pacific Islander White I do not identify as any of the above If you do not identify as any of the above and would like to share what you identify as, please do so below What are your pronouns? Leave blank if you prefer not to answer Where are you from? Leave blank if you prefer not to answer Would you like to be added to our mailing list to hear about future programming? * Yes No Thank you for registering for the 4th Annual Boston Pre-Intern Orientation Community Organizing Workshop on June 5, 2022. We will be in touch in May with more information. If you have any questions, please email Chrissie at cconnors@challiance.org
