Name:* First Last Email:* Phone:*OK to share contact information with current IIHC MS participants?*YesNoName of your current medical school:*Specialty of Interest*Headshot photo upload:*Please provide a headshot photo (jpeg file only) to be included in your online platform profile:Feel free to share any papers/articles you have written or anything that is of interest to you!PDF file Only"About Me" YouTube video link:* We would love to have a short Youtube video of you introducing yourself to the rest of your IIHC peers to include in your online profile, 2-3 minutes max. The video must include: your name, city of origin, and name of your medical school: 1) What motivated you to become a doctor? 2) How you have overcome challenges 3) How will IIHC be helpful to you or 4) Any accomplishments you would like to share (i.e., your work with any medical student association, high school programs, clinics, under-represented communities, etc.)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.PhoneThis field is for validation purposes and should be left unchanged.