HOST Student Registration Form

Please complete this form for each HOST travel request

Gender

Male Female

Name
Home Address
City
State
Zip
Home Phone
Mobile Phone
Email Address

Preferred time to reach you during the day: (time: to ) evening: (time: to )

If you will be traveling during the months of November-February (holiday, clinical rotations, other residency interviews, etc.), please provide approximate dates of travel and the suggested way to reach you during these periods:

Travel Log

(please complete the following for each travel destination for which housing is requested)

What are your dates in HOST interview city?

Arrival (mm/dd/yy)
Departure (mm/dd/yy)
Dates of overnight lodging (mm/dd/yy)
Interview Date (mm/dd/yy)

Medical Center/Program
Interview Specialty
City
State

Will your spouse/significant other be accompanying you? (not all hosts are able to accommodate)

Yes No

Any other comments you wish to add (special needs - i.e. smoking preference, allergies to household pets, etc.):

Contact

Medicine Alumni Society
medicine-alumni@uiowa.edu
Phone: 319-335-8886
Toll Free: 877-MEDIOWA
Fax: 319-384-1746