Volunteer as an Alumni HOST

Please complete this form and the Office of Alumni Affairs will contact you if your city matches a student's interview site. Thank you for volunteering!

Contact Information

First Name:
Last Name:
Maiden Name:
Primary Email:
Home Address:
Home City:
Home State:
Home Zip:
Primary Phone:
Graduation Year:
Specialty:
Subspecialty:
Gender:
 Female
 Male

 

Professional Information

Retired:
 Yes
 No
Employer:
Current Practice Type:
 Private Practice
 Clinic
 Hospital
 Research
 Faculty
 Other
Professional Title:
Office Address Line 1:
Office Address Line 2:
Office City:
Office State:
Office Zip:
Office Phone:
Office Fax:

 

Additional Information

Spouse Title/Salutation:
Spouse First Name:
Spouse Last Name:
Spouse Suffix:

 

Nearest Medical Center(s) and/or training hospitals:

 

How do you want the student to communicate with you?
 Call my primary phone
 Call my office
 Send me an email

 

I am willing to do the following to help a 4th year student during the interview process:
 Physical Hosting: Lodging
 Physical Hosting: Meal at your home or restaurant
 Physical Hosting: Transportation
 eHosting: General information about my city
 eHosting: General advice about residency programs in my area
 eHosting: General career advice to current LSU Med Students
 eHosting: Introduce the student to important colleagues at the hospital
Other ways I am willing to help (describe):