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

Please fill out this form if you would like to be a host, and someone from the MAA Medical Alumni Association will contact you about student requests in your area.

First Name: Required Field

Last Name: Required Field

Primary Email: Required Field

What is your specialty area? Required Field

Do you have experience or interest in the following:

Address 1: Required Field

Address 2:

City:

State:

Zip:

Phone Number: Required Field

Preferred Contact Method: Required Field

Preferred Contact Method: Phone
Email

Preferred Contact Time: Required Field

Preferred Contact Time: Morning
Afternoon
Evening

Preferred Student Gender: Required Field

Preferred Student Gender: Male
Female
Other
No preference

I am willing to provide: 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:

Please list any pets:

List of academic medical centers and teaching hospitals in your area:

Are you retired? Required Field

Are you retired? Yes
No

Where are you currently or most recently employed? Required Field

What is your current or most recent position? Required Field

Consider listing any prior positions:

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, AGREES 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 - Alumni Host Registration