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CHS Recruiting and Mentoring Registry
 
 
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If you are a high school student, college student or medical student or currently participating in a residency or fellowship program and would like to be a part of our Recruiting and Mentoring Registry, please complete this form.  Once we receive your completed form, you will be contacted with information about programs and special events related to your exploration of a career as a physician.

 

Last Name:
First Name:
Address: Street: 
City:  State:  ZIP:
   
Email Address:
Home Phone:      
Mobile Phone:
   
Date of Birth:  (mm/dd/yyyy)   
   
Do you want to practice medicine in western Pennsylvania?
 
   
Do you have a specialty area you are interested in?
 
Other:
   
Referral Source:
Other:
   
Name of High School:
Expected High School Graduation Date:
If already graduated, then list year:  
   
Have you participated in any of the following CHS Programs?
  Please check all that apply:
  Other, please specify:
   
Please list any friends or family members who work for CHS:
   
   
Please list any other information you would like to share with us:
   
   
Not all of the following may apply to you.  Please complete only the applicable questions:
   
Name of College - Undergraduate:
College Major:
College GPA:
College Expected Completion Date:
If already graduated, then list year:  
   
Name of Medical School:
Medical School GPA:
Medical School Expected Completion Date:
If already graduated, then list year:  
   
Residency Program/Location:
Residency Focus: (Please list specialty, FM, IM, etc...)
 
Residency Expected Completion Date:
If already completed, then list year:  
   
Fellowship Program Name:
Fellowship Location:
Fellowship Specialty:
Fellowship Expected Completion Date: