Host Program Form: Alumni Volunteer Request

Host Program Form: Alumni Volunteer Request

Welcome to the University of Illinois College of Medicine HOST Program alumni volunteer request form. The HOST Program is designed to assist students who are participating in the National Resident Matching Program (NRMP) and seeking residency placement in the coming year. This program aims to facilitate a connection between student requests and alumni volunteers who are able to host students or provide additional guidance for residency interviews in their local area.

HOST Program Process

We are in the process of formally building the HOST Program and are working to find optimal alumni volunteer hosts across the country to fit student requests. Please fill out the below alumni volunteer form. Once we receive your completed form we will store this information in our database. As student HOST requests are submitted we will evaluate compatibility of the information you provide to their HOST location request. If your volunteer information is compatible with a student request we will ask you to confirm your participation as a HOST Program volunteer. Once we have confirmed alumni interest and availability during indicated dates we will connect you directly with the student via email to confirm logistics.

We ask that when you connect with a student that you remember that you are a representative of the University of Illinois College of Medicine and our tradition of excellence and achievement; and that you conduct yourself in a professional and respectful manner while a student visits your city.

Fields in RED are mandatory

First Name 
Last Name 
Degree Type 
Additional Degrees 
Graduation Year(s) 
Specialty 
Preferred Contact Phone 
Phone Type 
Preferred Contact Email 
Preferred method of contact (please check all that apply) 


Email
Phone

RESIDENCE INFORMATION

  
Home Street Address 
Home Street Address 2 
City 
State 
Zip Code 
Closest Metropolitan Area(s) 
Spouse/Partner Name 
Non-smoking household 
Host household with children 
Household with pets 
Please describe 
Household dietary options 
HOST Program Volunteer Options – please check all that apply  HOST Homestay (provide lodging for a student in your home)
HOST Meal (share a networking meal with a student)
HOST Resource (provide local information and resources for a student coming to your area via phone or email, or assist a student on a month-long away rotation find affordable housing).
Are you interested in helping a student on a month-long rotation find affordable housing? 

PROFESSIONAL INFORMATION

  
Retired 
Professional Title 
Employer Name: 
Business Address 
Business Address 2 
City 
State 
Zipcode 
Business Phone 
Are you a member of a medical school’s faculty, leadership or on a residency program interview committee?  If yes, please explain
Additional Comments 
Terms and Condtions  I have read and agree to the terms and conditions of the waiver of liability, hold harmless and public release agreement for the University of Illinois College of Medicine HOST Program. Full document can be viewed here. 


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