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Student Application to Request a Virtual Advisor First Name: Middle Name/Initial: Last Name: Suffix (Jr., PhD, etc.): Gender: Male     Female E-mail (If you wish to participate in this program, your email address must be entered above.) Medical School: Albany Medical College Albert Einstein College of Medicine Arizona College of Osteo Med Baylor College of Medicine Boston University School of Medicine Brody School of Medicine at East Carolina University Brown University School of Medicine Case Western Reserve University School of Medicine Chicago College of Osteo Med Columbia University College of Physicians and Surgeons Creighton University School of Medicine Dalhousie University Faculty of Medicine Dartmouth Medical School Des Moines U-Osteo Medical Center Duke Universtiy School of Medicine East Tennessee State University James H. Quillen College of Medicine Eastern Virginia Medical School of the Medical College of Hampton Roads Emory Universtiy School of Medicine Finch Universtiy of Health Science/The Chicago Medical School George Washington University School of Medicine and Health Sciences Georgetown University School o f Medicine Harvard Medical School Howard University College of Medicine Indiana University School of Medicine Jefferson Medical College of Thomas Jefferson University Joan & Sanford I. Weill Medical College Cornell University Joan C. Edwards School of Medicine at Marshall University Johns Hopkins University School of Medicine Keck School of Medicine at the University of Southern California Kirksville College of Osteo Med Lake Erie Colle of Osteo Med Laval University Faculty of Medicine Loma Linda Universtiy School of Medicine Louisiana State University School of Medicine in New Orleans Loyola University Chicago Stritch School of Medicine MCP Hahnemann University School of Medicine Mayo Medical School McGill University Faculty of Medicine McMaster University School of Medicine Medical College of Georgia School of Medicine Medical College of Ohio Medical College of Wisconsin Medical University of South Carolina College of Medicine Meharry Medical College School of Medicine Memorial University of Newfoundland Faculty of Medicine Mercer University School of Medicine Michigan State University College of Human Medicine Michigan State U. College of Osteo Med Morehouse School of Medicine Mount Sinai School of Medicine of New York University New York College of Osteo Med New York Medical College New York University School of Medicine Northeastern Ohio Universities College of Medicine Northwestern University Medical School Nova Southeastern U. College of Osteo Med Ohio State University College of Medicine and Public Health Ohio U. College of Osteo Med Oklahoma State U. College of Osteo Med Oregon Health Sciences University School of Medicine Pennsylvania State University College of Medicine Philadelphia College of Osteo Med Pikeville College of Osteo Med Ponce School of Medicine Queen's University Faculty of Health Sciences Rush Medical College of Rush University Saint Louis University School of Medicine Southern Illinois University School of Medicine Stanford University School of Medicine SUNY Health Sciences Center at Brooklyn College of Medicine SUNY Health Science Center at Syracuse College of Medicine SUNY Health Science Center at Stony Brook School of Medicine SUNY at Buffalo School of Medicine & Biomedical Sciences Temple University School of Medicine Texas A&M University System Health Science Center College of Medicine Texas College of Osteo Med Texas Tech University Health Sciences Center School of Medicine Touro U. College of Osteo Med Tufts University School of Medicine Tulane Universtiy School of Medicine UMDNJ-New Jersey Medical School Uniformed Services U. of the Health Sciences F. Edward Hebert School of Medicine Universidad Central del Caribe School of Medicine Universite de Montreal Faculty of Medicine Universite de Sherbrooke Faculy of Medicine U. of Alabama School of Medicine U. of Alberta Faculty of Medicine and Dentistry U. of Arizona College of Medicine Arizona Health Sciences Center U. of Arkansas College of Medicine U. of British Columbia Faculty of Medicine U. of Calgary Faculty of Medicine U. of California, Davis, School of Medicine U. of California, Irvine, College of Medicine U. of California, Los Angeles, UCLA School of Medicine U. of California, San Diego, School of Medicine U. of California, San Francisco, School of Medicine U. of Chicago, Division of the Biological Sciences The Pritzker School of Medicine U. of Cincinnati College of Medicine U. of Colorado Health Sciences Center School of Medicine U. of Connecticut School of Medicine U. of Florida College of Medicine U. of Hawaii John A. Burns School of Medicine U. of Health Sciences College of Osteo Med U. of Illinois College of Medicine U. of Iowa College of Medicine U. of Kansas School of Medicine U. of Kentucky College of Medicine U. of Louisville School of Medicine U. of Manitoba Faculty of Medicine U. of Maryland School of Medicine U. of Massachusetts Medical School U. of Medicine and Dentistry of New Jersey School of Osteo Med U. of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School U. of Miami School of Medicine U. of Michigan Medical School U. of Minnesota Medical School - Twin Cities U. of Minnesota -  Duluth School of Medicine U. of Mississippi School of Medicine U. of Missouri - Columbia School of Medicine U. of Missouri - Kansas City School of Medicine U. of Nebraska College of Medicine U. of Nevada School of Medicine U. of New England College of Osteo Med U. of New Mexico School of Medicine U. of North Carolina at Chapel Hill School of Medicine U. of North Dakota School of Medicine and Health Sciences U. of Oklahoma College of Medicine U. of Ottawa Faculty of Medicine U. of Pennsylvania School of Medicine U. of Pittsburgh School of Medicine U. of Puerto Rico Schoolof Medicine U. of Rochester School of Medicine and Dentistry U. of Saskatchewan College of Medicine U. of South Alabama College of Medicine U. of South Carolina School of Medicine U. of South Florida College of Medicine U. of South Dakota School of Medicine U. of Tennessee, Memphis, College of Medicine U. of Texas Medical School at San Antonio U. of Texas Southwestern Medical Center at Dallas Southwestern Medical School U. of Texas - Houston Medical School U. of Texas Medical Branch at Galveston U. of Toronto Faculty of Medicine U. of Utah School of Medicine U. of Vermont College of Medicine U. of Virginia School of Medicine U. of Washington School of Medicine U. of Western Ontario Faculty of Medicine & Dentistry U. of Wisconsin Medical School Vanderbilt University School of Medicine Virginia Commonwealth University School of Medicine Wake Forest University School of Medicine Washington University School of Medicine Wayne State University School of Medicine West Virginia School of Osteo Med West Virginia University School of Medicine Western University of Health Sciences Wright State University School of Medicine Yale University School of Medicine If Other, Medical School: Year in Medical School 1st     2nd     3rd     4th MD/PhD     Intern/Resident Other Intern/Resident Specialty: No Current Residency Allergy and Immunology Anesthesiology Colon and Rectal Surgery Dermatology Diagnostic Radiology Emergency Medicine Family Practice Internal Medicine Neurology Neurological Surgery Nuclear Medicine Obstetrics and Gynecology Ophthalmology Orthopedic Surgery Otolaryngology Pathology Pediatrics Preliminary Internal Medicine Preventive Medicine Primary Care Psychiatry Radiation Oncology Radiology Surgery Thoracic Surgery Transitional Year Urology Other If Other Specialty, Specify: Interest in EM as a career Decided     Probable     Considering What other specialty are you considering? Allergy and Immunology Anesthesiology Colon and Rectal Surgery Dermatology Diagnostic Radiology Emergency Medicine Only Family Practice Internal Medicine Neurology Neurological Surgery Nuclear Medicine Obstetrics & Gynecology Ophthalmology Orthopedic Surgery Otolaryngology Pathology Pediatrics Physical Medicine & Rehabilitation Plastic Surgery Preventive Medicine Primary Care Psychiatry Radiation Oncology Radiology Surgery Thoracic Surgery Urology Other If Other, What Specialty? Do you have an EM physician as an advisor already? Yes     No If yes, what type of advisor do you have? No advisor at present EM residency program faculty member EM physician (board certified) EM physician (not board certified) Other Do you have an EM residency at your medical school? Yes     No Why are you interested in an EM Virtual Advisor? (check all that apply) Don't have an EM advisor Would like some extra mentorship Second Opinion Special interest mentor Interest:   Other:  What is your regional preference for an advisor? (An attempt will be made to accommodate requests based on availability.) No regional preference Northeast Midatlantic Southeast Midwest Central Northwest Southwest Would you be interested in meeting with your advisor at a national or regional meeting? Yes     No   Note: Clicking submit will send an email to the virtual advisor program. You will receive confirmation via email once a virtual advisor has been assigned.

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