Wisconsin Neuro Targeted SIM Registration » Wisdom in Diagnostic Imaging » College of Medicine

UF/WIDI SIM Registration Form

Program

Program - Name(Required)

Program - Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Residency Program Director

Residency Program Director - Name(Required)

First Last

Residency Program Director - Email(Required)

Residency Program Director - Phone(Required)

Program Coordinator

Each participating institution must specify an individual (frequently the residency program coordinator) who will serve as the institution's liaison. Each institution's liaison will be responsible for registering the program and residents; submitting payment; ensuring the workstations are setup and confirming system readiness; and scheduling each resident for the SIM.

Program Coordinator - Name(Required)

First Last

Program Coordinator - Email(Required)

Program Coordinator - Phone(Required)

Residents

Please enter the names of all residents that will be scheduled to take the SIM and specify current year in program (1st year resident; 2nd year resident; 3rd year resident; 4th year resident).

Resident 1

First Last

Resident 1 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 1 Email

Resident 2

First Last

Resident 2 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 2 Email

Resident 3

First Last

Resident 3 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 3 Email

Resident 4

First Last

Resident 4 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 4 Email

Resident 5

First Last

Resident 5 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 5 Email

Resident 6

First Last

Resident 6 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 6 Email

Resident 7

First Last

Resident 7 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 7 Email

Resident 8

First Last

Resident 8 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 8 Email

Resident 9

First Last

Resident 9 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 9 Email

Resident 10

First Last

Resident 10 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 10 Email

Resident 11

First Last

Resident 11 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 11 Email

Resident 12

First Last

Resident 12 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 12 Email

Resident 13

First Last

Resident 13 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 13 Email

Resident 14

First Last

Resident 14 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 14 Email

Resident 15

First Last

Resident 15 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 15 Email

Resident 16

First Last

Resident 16 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 16 Email

Resident 17

First Last

Resident 17 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 17 Email

Resident 18

First Last

Resident 18 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 18 Email

Resident 19

First Last

Resident 19 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 19 Email

Resident 20

First Last

Resident 20 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 20 Email

Resident 21

First Last

Resident 21 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 21 Email

Resident 22

First Last

Resident 22 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 22 Email

Resident 23

First Last

Resident 23 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 23 Email

Resident 24

First Last

Resident 24 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 24 Email

Resident 25

First Last

Resident 25 - Year in Program

1 - 1st year resident

2 - 2nd year resident

3 - 3rd year resident

4 - 4th year resident

Resident 25 Email