Volunteer for SAID

Alumni Registration Form

Name*

First Last

What are your pronouns?*

Please list all UW Medicine degrees and/or medical training with graduation/completion years*

UW Medicine E-year

E-year refers to the year you began your MD degree program, if applicable

Email*

Enter Email Confirm Email

Preferred contact number*

Please enter as ###-###-####.

Specialty*

Provide a brief bio we can share with students when they register for SAID. We suggest you include where you practice(d), as well as information about your career path, your hobbies and your personal and professional achievements.*

Themes/topics I can touch on during my session:

Select all that apply

*Practice Setting*

select all that apply

Private/solo practice

Group practice

Hospitalist

Academic medicine

Rural medicine

Industry

**Please indicate the identity/ies on which you'd like to speak:*

***Please indicate other topic or interest area here:*

Event Information

Event Location*

Alumni are welcome to host students either virtually or in-person. If in-person, it must be within 30 minutes of a WWAMI campus.

Virtual

Seattle, WA

Spokane, WA

Laramie, WY

Anchorage, AK

Bozeman, MT

Moscow, ID

Location Type*

Private residence

Restaurant/cafe

Office

Virtual: I will provide my own link

Virtual: I will need a link

TBD

Other

Location Address (skip if virtual)

This address will not be made public, and will only be shared with the students that register for your session. Leave blank if TBD.

For in-person sessions: will you be providing or covering the cost of food?

There is no obligation to provide or pay for student meals. We just want to ensure students are informed.

Please indicate a date for your session, between October 7 and December 14 (we recommend that you avoid Sunday night, as students often have exams on Mondays, which could affect attendance).

Be mindful of holidays: Oct. 11-12 Yom Kippur; Nov. 1 Diwali; Nov. 11 Veterans Day; Nov. 28 Thanksgiving Day; Nov. 29 Native American Heritage Day

Event start time*

Event end time*

We recommend planning for events that last one to two hours. Virtual events tend to work best with a 90 minute timeframe, while in person events tend to last longer.

Your timezone*

How many students are you able to host for the discussion?*

Co-Host Information

Would you like to host your event with a fellow alum?*

Yes

Co-host name

Co-host specialty

Co-host email

Please tell us a bit about your co-host. We will share this information with students when they register for SAID. We suggest you include where they practice(d), as well as information about their career path, hobbies and personal and professional achievements.*