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Dermatology Residents Application

Thank you for your interest in attending the 2024 Dermatology Residents' and Rheumatology Fellows' Meeting. Please complete the form below to be considered for the one-and-a-half-day conference to be held in Salt Lake City on Saturday, October 19, and Sunday, October 20.

Personal Information

First Name:

Middle Name:

Last name:

LinkedIn username

Date of Birth (mm/dd/yy):

Email address:

Mailing Address:

City:

State:

Zip code:

Cell Phone Number

Gender:

Male

Female

Non-Binary/Other

Which of the following best describes your race?

White or CaucasianBlack or African AmericanAmerican Indian or Alaska NativeAsianNative Hawaiian or Other Pacific IslanderSome other raceI prefer not to answer

Do you consider yourself Hispanic/Latinx?

YesNoI prefer not to answer

Dermatology Residency Information

Residency Program Name:

University and/or Medical Center (if different):

Residency Director Name:

Director's Email Address:

Year of Residency:

I have previously attended this event

Yes

No

On average, how many hours of psoriasis-specific education do you receive per residency year?

Which of the following barriers do you encounter when managing psoriasis patients (check all that apply)?

Insurance requirementsLack of influence over treatment decisions Patient non-complianceTolerability and adverse effects associated with treatmentLack of time/support staffLack of knowledge of strategies for psoriatic disease managementTreatment limitations due to comorbid conditions

Please tell us why you would like to attend the 2024 Residents' and Fellows' Meeting.

Please keep your response to 250 words.

Travel Information

I require hotel accommodations:

Yes

No

I would like to be considered for a scholarship to support my travel (non-local residents only)

Yes

No

Any Dietary Restrictions?

NoneKosherNutVegetarianOther

Please specify:

I have read and agree to the additional information on: www.psoriasis.org/residents-meeting-travel.

Yes

Educational sessions will run from 8:00 a.m. October 19 to 1:00 p.m. October 20. By submitting this application, I agree to arrange my travel plans accordingly and attend all required lectures on Saturday and Sunday. I understand that if I don’t adhere to NPF’s attendance policy, as well as complete all pre/post-conference activities (pre-test, post-test, evaluation), I will be subject to financial penalties for expenses incurred on my behalf.

Contact Information

Questions?

Email us at medicalaffairs@psoriasis.org.

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