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