Please complete the information below to be added to the
waitlist
for the HS Academy.
General Information
Full Name
*
First Name
Last Name
Credentials
*
MD, DO, etc.
Professional E-mail
*
example@example.com
Personal E-mail
*
Please provide your personal email address so we can stay in contact with you after you move on from your program.
Cell Phone Number
*
Format: (000) 000-0000.
Preferred Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you attended HS Academy in the past?
*
Yes
No
Please indicate which year(s) you attended in the past.
*
2021
2022
2023
2024
Residency Program
Dermatology Training Year
*
1
2
3
What is the name of your residency program?
*
Is there an HS specialist at your program?
*
Yes
No
Who is the HS specialist at your program?
*
In one sentence, why do you want to attend this event?
*
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