University of Pittsburgh Philanthropic & Alumni Engagement - Host - Student Registration Form

Once you register, you will hear from us shortly. If you have any additional questions, please email them to hsalumni@pitt.edu. Please fill out the questions below to help us provide the best match. While we cannot guarantee a host to meet all of your selections, we will do our best.

Contact Information

First Name: Required Field

Last Name: Required Field

Primary E-mail: Required Field

Phone Number: Required Field

Host Preferences

Host gender: Required Field

Host gender: Please Choose
Male
Female
No preference

I would like the host to provide the
following: Required Field

Use Ctrl or Shift keys to multi-select.

Would you prefer to meet virtually? Required Field

Would you prefer to meet virtually? Yes
No

If you are willing to meet only virtually, please check this box:

Location of Interview/Medical
Center Location: Required Field

What is the specialty for which you are interviewing? Required Field

Interview Date: Required Field

Open the calendar popup.

What evening(s) will you require lodging in this area? (If you do not need overnight accommodations, please write n/a) Required Field

Will your spouse or significant other accompany you? Required Field

Will your spouse or significant other accompany you? Yes
No
Maybe

Additional Comments (including special needs, allergies, etc.):

By registering, I acknowledge and agree to the following:

DISCLAIMER AND WAIVER OF LIABILITY: (a) PITT/UPSOM’s sole role is to connect students and alumni (“Participants”) for the limited purposes of the Help Our Students Travel (HOST) program; (b) PITT/UPSOM is not responsible for any Participant’s costs or expenses related to or incurred due to participation in the program (e.g., travel, accommodation, meals, etc.) and travel insurance is recommended; (c) PITT/UPSOM does not supervise, manage, or control the communications or ensuing interactions between students and alumni; (d) Participation in the HOST program is voluntary and is not a condition of matriculation for students nor will it have an effect on alumni status; and (e) IN EXCHANGE FOR AND BY PARTICIPATING IN, THE HOST PROGRAM, EACH PARTICIPANT, ON BEHALF OF THEMSELVES, THEIR HEIRS AND ASSIGNS, AGREE TO ASSUME THE RISKS INVOLVED IN THE HOST PROGRAM AND HOLD HARMLESS PITT/UPSOM AND ITS OFFICERS, DIRECTORS, FACULTY AND STAFF FOR ALL EXPENSES, COSTS, LOSSES, INJURIES, OR DAMAGES (INCLUDING ATTORNEY’S FEES) RELATED TO PERSONAL INJURY OR PROPERTY DAMAGE THAT STUDENTS, ALUMNI, OR ANY OTHER INDIVIDUAL MAY INCUR OR SUFFER IN CONNECTION WITH OR ARISING FROM PARTICIPATING IN THE HOST PROGRAM. Required Field

Participant Initial Here: Required Field

HOST Registration - Fourth Year Students