ACGME Hub Course Registration — The Peter L. Slavin, MD Academy for Applied Learning in Health Care

First Name(s)

Last Name(s)

Degree(s)

(e.g., MD, DO, PhD)

Which of the following best describes your current role?

Resident

Resident on an academic development year

Fellow

Attending

Other (if applicable specify below)

Other role:

Preferred Email

Primary Specialty

Other specialty

Institution/Hospital Affiliation

MGH, BWH, MEE, Spaulding, Faulker, Community Health Centers, etc.

Best Contact Cell Phone Number

Assistant Name and Phone (for scheduling/urgent issues)

Dietary Restrictions/Allergies (we should be aware of for provided meals/refreshments)

None

Kosher

Halal

Vegetarian

Vegan

Gluten-Free

Other (Specify below)

Please detail specific dietary restrictions or allergies

e.g., milk, eggs, fish, shellfish, tree nuts, peanuts, etc.