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

Name*

First Last

Address*

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

KP (or other Organization) Email*

Personal Email*

Phone*

Degree(s)*

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

Residency Site*

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

Specialty*

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

Current Year of Training (indicate year of training at the time of the course)*

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 has completed this survey.
I cannot attest.

Please tell us why you are interested in taking part in the Residency Elective in Health Policy (3-5 sentences).*

Please write about a healthcare or health policy issue that most concerns you (3-5 sentences).*

Describe a situation when you made a significant impact. This can be in community engagement, medical practice, or other settings (3-5 sentences).*

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.

Please attach your short biography (*170-200 words max) and current picture. 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 items will be included in the course program.*

Drop files here or

Emergency Contact*

First Last

Relationship*

Email*

Phone*

Food allergies/dietary restrictions