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 Phone Format as 123-456-7890Cell Phone Format 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 Time Format as 00:00, in 0.25 hour incrementsTrainee End Date* Format as MM/DD/YYYYTrainee End Time Format as 00:00, in 0.25 hour incrementsCourse Title If applicableCourse Number If applicableCourse Section Number If applicableUF Faculty Supervisor If applicableTotal Credit Hours Needed for Internship If applicableTotal Hours of Trainee Program at SHCC for Semester If applicable
