Complete this form for your resident/fellow applicant(s). ALL applicants must have their PD approval to be considered for the course. Do you want to submit response for more than one resident or fellow at this time?* Yes No Resident/Fellow's Name* First Last I verify that the above applicant is in good standing and has been granted protected release time to participate from Monday, October 2, 2023 - Friday, October 13, 2023.* Yes, the resident/fellow can attend. No, the resident/fellow cannot attend. Other If "Other" was selected, please explain below.* Additional Resident and/or Fellow ApprovalsYou can submit response for up to 5 additional residents/fellows.(2) Resident/Fellow's Name* First Last (2) I verify that the above applicant is in good standing and has been granted protected release time to participate from Monday, October 2, 2023 - Friday, October 13, 2023.* Yes, the resident/fellow can attend. No, the resident/fellow cannot attend. Other If "Other" was selected, please explain below.* (3) Resident/Fellow's Name First Last (3) I verify that the above applicant is in good standing and has been granted protected release time to participate from Monday, October 2, 2023 - Friday, October 13, 2023. Yes, the resident/fellow can attend. No, the resident/fellow cannot attend. Other If "Other" was selected, please explain below.* (4) Resident/Fellow's Name First Last (4) I verify that the above applicant is in good standing and has been granted protected release time to participate from Monday, October 2, 2023 - Friday, October 13, 2023. Yes, the resident/fellow can attend. No, the resident/fellow cannot attend. Other If "Other" was selected, please explain below.* (5) Resident/Fellow's Name First Last (5) I verify that the above applicant is in good standing and has been granted protected release time to participate from Monday, October 2, 2023 - Friday, October 13, 2023. Yes, the resident/fellow can attend. No, the resident/fellow cannot attend. Other If "Other" was selected, please explain below.* (6) Resident/Fellow's Name First Last (6) I verify that the above applicant is in good standing and has been granted protected release time to participate from Monday, October 2, 2023 - Friday, October 13, 2023. Yes, the resident/fellow can attend. No, the resident/fellow cannot attend. Other If "Other" was selected, please explain below.* Program Director DetailsYour Name* First Last Your Email* Your Specialty/Program*Emergency MedicineFamily MedicineGeneral SurgeryInternal MedicineObstetrics & GynecologyOtolaryngologyPediatricsPodiatric SurgeryPsychiatryOtherIf you selected "Other" Specialty/Program, please provide specialty/program name.* Medical Center*Modesto - Central ValleyNapa-SolanoOaklandSacramentoSan FranciscoSan JoseSanta ClaraSanta RosaOtherIf "Other" Medical Center selected, please provide the center's name.* KP Region*Northern CaliforniaSouthern CaliforniaHawaiiMid-Atlantic StatesWashingtonN/A - External to KPYour Phone*