Trainee Registration Form First Name*Last Name*UF ID Number*UF E-mail Address*Trainee Status* Student - Undergraduate Student - Graduate/Professional Medical Resident - PGY 1 Medical Resident - PGY 2 Medical Resident - PGY 3 Shadow Volunteer Other Local Street Address*City*State*Zip Code*Home PhoneFormat as 123-456-7890Cell PhoneFormat as 123-456-7890School/College/Institution (ex: College of Medicine)*Planned Program/Program of Study*Who will be your preceptor at the SHCC?*Trainee Start Date*Format as MM/DD/YYYYTrainee Start TimeFormat as 00:00, in 0.25 hour incrementsTrainee End Date*Format as MM/DD/YYYYTrainee End TimeFormat as 00:00, in 0.25 hour incrementsCourse TitleIf applicableCourse NumberIf applicableCourse Section NumberIf applicableUF Faculty SupervisorIf applicableTotal Credit Hours Needed for InternshipIf applicableTotal Hours of Trainee Program at SHCC for SemesterIf applicable
