×Close Timeout Warning Your session is about to time out, do you want to continue your session? 60s left. Virtual Medical Student Outreach Program Registration Form Wednesday, April 14th 6pm- 8:30pm EDT First Name * Last Name * Email * Day Phone * Address * City * State/Province * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip * If you have previously participated in a Medical Student Outreach Program, please state the program location and year below. Previous Medical Student Outreach Program Medical School Name * Current Year in Medical School * MS-1 MS-2 MS-3 MS-4 Anticipated Graduation Year * 2021 2022 2023 2024 2025 Race American Indian/Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White The above information is collected for reporting purposes only and will not be used in the student selection process. Ethnicity Hispanic or Latino Not Hispanic or Latino The above information is collected for reporting purposes only and will not be used in the student selection process. Communication Disclaimer * By checking this box, I acknowledge that I will be contacted by The Perry Initiative via email and I *must* confirm my attendance. If I do not, the next person on the waitlist may be admitted. Powered by Neon CRM