Name:* First Last Email:* Phone:*OK to share phone number with current IIHC MS participants?*YesNoName of your current medical school or residency program:*I am a:*Medical StudentIIHC AlumKP ResidentProgram DirectorOtherIf Other, please specify:If Resident, PGY Year:Specialty or specialty of interest:*Headshot photo upload (medical students only):jpeg file strongly encouragedFeel free to share a paper/article you wrote or anything that is of interest to you!PDF file strongly encouragedYouTube or other sharing platform video link strongly preferred (if video link not available, please upload compressed video below) Video of you, 4 minutes or less to include: your name, city of origin, and name of your medical school or residency program: - What motivated you to become a doctor - IIHC experience, if alumn or previous site director and - Either: 1) How you have overcome challenges 2) How IIHC was helpful (if a previous participant, if not, how do you think IIHC will be helpful.) 3) How you studied for USMLE or 4) Any accomplishments you would like to share (i.e., your work with any medical student association, high school programs, clinics, etc.)Video Upload (max 40MB):Upload your video here (as described above) if a shared link is not available. Photo Release:*I Grant PermissionI DeclineI hereby grant Kaiser Foundation Health Plan, Inc.(KFHP), Kaiser Foundation Hospitals(KFH), The Permanente Medical Group, Inc.(PMG), also commonly known as the Kaiser Permanente Medical Care Program (“Program”), their personnel or contractors, all rights and consent to copyright, use, or re-use, publish, or re-publish, copy, exhibit or distribute all photographs, videotapes, motion picture ﬁlms and/or audio tapes involving the use of my voice or image, by the Program for internal use, education use, advertising or promotion without restriction as to frequency or duration of usage and without compensation to me. This agreement may only be modiﬁed in writing, signed by the parties. I hereby certify that I am at least 18 years of age and have full right and authority to grant the consent and rights in my own name in this agreement. I have read the above consent and agreement, prior to its execution, and I am fully familiar with the contents thereof. I hereby grant my permission and consent to all the foregoing.NameThis field is for validation purposes and should be left unchanged.