Resident/Fellow's Name* First Last Current Year of Training (indicate year of training at the time of course)*PGY-1PGY-2PGY-3PGY-4 or greaterFellowOtherIf "Other" PGY Level selected, please explain.Specialty*Family MedicineGeneral SurgeryInternal MedicineObstetrics & GynecologyOtolaryngologyPediatricsPodiatric SurgeryPsychiatryOtherIf "Other" Specialty selected, please provide the specialty name.Medical Center*Napa-SolanoOaklandSacramentoSan FranciscoSan JoseSanta ClaraSanta RosaOtherIf "Other" Medical Center selected, please provide the center's name.Region*Northern CaliforniaSouthern CaliforniaHawaiiWashingtonOtherIf "Other" Region selected, please explain.Your Name* First Last Your Specialty/Program*Family MedicineGeneral SurgeryInternal MedicineObstetrics & GynecologyOtolaryngologyPediatricsPodiatric SurgeryOtherIf you selected "Other" Specialty/Program, please provide specialty/program name.Your Email* Your Phone*I verify that the above applicant is in good standing and has been granted protected release time to participate from Monday, October 5, 2020 - Friday, October 16, 2020.* Yes, the resident/fellow can attend. No, the resident/fellow cannot attend. Other If you answered 'other' to the above, please explain.