Register for the 3rd 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 at the beginning of June) Academic Medical Center? * i.e. MGH Residency Program * i.e. Internal Medicine What Year of Residency will you be starting in July 2021 * 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 workshop on Sunday, June 13th from 9AM-4PM? 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 13th I am unsure at this time, but will email Chrissie Connors at cconnors@challiance by Friday, May 21, 2021 to confirm my full participation or I understand that my spot will be given to someone else. For the purposes of creating diverse small groups, please share the following information if you are comfortable. What race / ethnicity are you? Leave blank if you prefer not to answer Pronouns? Leave blank if you prefer not to answer Where are you from? Leave blank if you prefer not to answer Would you be interested in future community organizing and health equity programs developed by this group? * Yes No Would you like to be added to our mailing list? * Yes No Thank you for registering for the 3rd Annual Boston Pre-Intern Orientation Community Organizing Workshop on June 13, 2021. We will be in touch at the end of May with more information. If you have any questions, please email Chrissie at cconnors@challiance.org
