(Please use Internet Explorer to fill out and submit the Reservation Request form.)

*Name:
*Class Year:
OSU MD and/or residency completion
Gender:
Home Address Information
*Street:
*City:
*State:
*Zip:
*Metropolitan Area:
Phone:
Cell phone:
Email:
Employment Address Information
*Name of Business:
*Street:
*City:
*State:
*Zip:
Phone:
Email:
Spouse Information (If applicable)
Preferred phone contact:
Preferred email address:
*Training hospitals in your area:
At what hospital did you receive your residency training?
*Hospital Name:
*Hospital City/State:
*What year did you complete your residency training:
*What is your medical specialty:
Your home environment
*Type of dwelling:
(home, apartment, condo, etc.)
Other people living in your home:
Pets in the home:
Does anyone in your home smoke:
Do you have a preference of weekday or weekend visits:
Would there be any times when you are unavailable to host students:
(holidays, vacations, etc.)
Would you be willing to take more then one student:
If yes, how many:
Please match me with a student of the following gender:
I am willing to provide: