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7/30/2019 UT SHAPE Invitation and Information Packet Reply
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UT SHAPE
Interview Weekend, February 22 and 23, 2013
We look forward to welcoming you to UT Southwestern! Please take a few minutes to provide us with some
information as we prepare for your arrival. You may fax your responses to 214.648.3289 or email them to:
[email protected] . Call or email me if you have any questions or concerns. Please, share my
contact information with your family!
Thanks so much!
Anne
Anne P McLane
Associate Director of Admissions
214 648 5620 direct, 214 648 5617 main, 214 418 0208 mobile, [email protected]
Your Name: _William Ip_____________________ Preferred First Name: ____William_____________________
Emergency Contact Name: _____Wai Kuen Chui___________________________________________________Emergency Contact Phone: ____6825540464________ Relationship to you: ___Mother___________________
Are you a vegetarian? __no____ Other dietary restrictions ____none_________________________________
The interview weekend:
Friday Clinical Rounds (Optional) -- The program begins at 8 a.m. on 2/22/13
Will you be attending the Friday Clinical Rounds program? __yes____
Note: You must complete the HIPAA 363 training module BEFORE arrival and bring a copy of my certificate with
you on Friday morning.
Friday Afternoon Program (Required) -- Your Friday Afternoon Program begins at 1 p.m.I will be bringing a guest(s) to the Friday Afternoon Program ______
-If you are bringing a guest (or guests)
-Guest 1 Name: __________________________ Vegetarian? _______ Other dietary restrictions ______ -
Guest 2 Name: __________________________ Vegetarian? _______ Other dietary restrictions ______
I will be attending the Friday Dinner with UT Southwestern Students _yes____
I will be bringing a guest(s) to the Friday Dinner
-If you are bringing a guest (or guests)
-Guest 1 Name: __________________________ Vegetarian? _______ Other dietary restrictions ______ -
Guest 2 Name: __________________________ Vegetarian? _______ Other dietary restrictions ______
Saturday Interview Sessions (Required) -- Your Saturday events begin at 8:30 a.m. 2/23/13
I will be bringing a guest(s) to the Saturday Program _____-If you are bringing a guest (or guests) _____
-Guest 1 Name: __________________________ Vegetarian? _______ Other dietary restrictions ______ -
Guest 2 Name: __________________________ Vegetarian? _______ Other dietary restrictions ______
I would like to stay with a UT Southwestern Student during my visit ____no______
Thursday night _____ Friday night _____
(We cannot accommodate your guests with student accommodations
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7/30/2019 UT SHAPE Invitation and Information Packet Reply
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