Please complete the information below to be added to the
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for the HS Academy.
General Information
Full Name
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First Name
Last Name
Credentials
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MD, DO, etc.
E-mail
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example@example.com
Cell Phone Number
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Preferred Mailing Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you attended HS Academy in the past?
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Please indicate which year(s) you attended in the past.
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2021
2022
2023
Residency Program
Dermatology Training Year
*
1
2
3
What is the name of your residency program?
*
In one sentence, why do you want to attend this event?
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