Residency Elective in Health Policy - Resident Application | Kaiser Permanente Undergraduate & Graduate Medical Education Northern California

Please use Chrome to submit your application

Name*

First Last

Hidden

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

KP (or other Organization) Email*

*This primary email will be used first for email communication for application status/follow-up and throughout the program, if selected to participate.

Alternative Email*

Phone*

*Please put your preferred number for communication throughout the course, including being added to a Whatsapp group.

Degree(s)*

If "Other" degree selected, please provide degree type(s).*

Hidden

Degree(s)*

Hidden

If "Other" degree selected, please provide degree type.

Residency or Fellowship Site*

If "Other" Residency or Fellowship Site selected, please provide site name.*

Specialty*

If "Other" Specialty selected, please provide the specialty name.*

Year of Training*

Indicate your training year at the time of the course in October 2022.

If "Other" Training year selected, please explain.*

Program Director Name*

First Last

Name of Program Coordinator/Residency Program Administrator*

First Last

Program Director Work Email Address*

Program Director Work Phone*

Please attest that your residency director will complete the "Program Director Approval Form" by the application deadline. This confirms your ability to participate in the elective. They can complete the survey at: https://residency-ncal.kaiserpermanente.org/rehp-pd-approval/*

I attest that my program director will or has completed the approval form.
I cannot attest.

Short Answer Section: All responses should be thorough and comprehensive. (1-2 paragraphs per answer)

Please tell us why you are interested in taking part in the Residency Elective in Health Policy (1-2 paragraphs).*

Please write about a healthcare or health policy issue that most concerns you (1-2 paragraphs).*

Describe a situation when you made a significant impact and how has this impacted you on a personal or professional level . This can be in community engagement, medical practice, or other settings (1-2 paragraphs).*

Check here to attest that you can participate in the entire course.*

I attest that I can participate in the entire course.
I cannot attest.

*OPTIONAL: For attestation of course attendance, please provide a brief explanation of any anticipated excused absences, ALREADY APPROVED by your PD (ex. a test that cannot be rescheduled that will happen during the course).

Please attach your short biography (*170-200 words max / 3rd person perspective). Your biography can include information about yourself that focuses on events and/or your involvement in health policy and or community health issues. **If accepted into the course, the attached item will be included in the course program and shared with course speakers and participants.*

Drop files here or

Accepted file types: jpg, png, pdf, docx, Max. file size: 50 MB.

Please attach a current picture. **If accepted into the course, the attached item will be included in the course program and shared with course speakers and participants*

Accepted file types: jpg, png, pdf, docx, Max. file size: 50 MB.

Emergency Contact*

First Last

Relationship*

Email*

Phone*

Hidden

Food allergies/dietary restrictions

Name

This field is for validation purposes and should be left unchanged.