{"id":11958,"date":"2020-11-04T13:00:10","date_gmt":"2020-11-04T18:00:10","guid":{"rendered":"https:\/\/www.bumc.bu.edu\/care\/?page_id=11958"},"modified":"2024-08-20T11:28:42","modified_gmt":"2024-08-20T15:28:42","slug":"chief-resident-online-application","status":"publish","type":"page","link":"https:\/\/www.bumc.bu.edu\/care\/chief-resident-online-application\/","title":{"rendered":"Chief Resident Online Application"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_80' style='display:none'>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">24th Annual Chief Resident Immersion Training (CRIT) Program in Addiction Medicine: CHIEF RESIDENT Application<\/h3>\n                            <p class='gform_description'><p>To complete the application process, we require: \r\n<p><b>1)<\/b> A CV.\r\n<p><b>2)<\/b> A personal statement of no more than 500 words that describes your motivation and goals for participating in the CRIT Program, your interest in addiction medicine, your plans for disseminating the knowledge and skills gained at CRIT to your learners, and your ideas for integrating addiction medicine into your residency program's curriculum.\r\n<p><b>3)<\/b> A letter of nomination addressed to the CRIT directors from your residency program director that includes the percentage of time in your chief residency that will be dedicated to teaching.\r\n<p><b>4)<\/b> A letter of support to the CRIT directors from a faculty member (mentor) who will support the integration of addiction medicine into your institution's curriculum. <i>If your residency director is also your mentor, only one letter is needed.<\/i><\/p>\r\n\r\n<p><b>Note:<\/b> If your faculty mentor is applying along with you and completing an online application, their application will serve as this letter of support.<\/p><\/P>\r\n\r\n<p> If you experience any issues while filling out this application, please contact Senior Program Manager Jules Canfield at <b>Jules.Canfield@bmc.org<\/b>.<\/p><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_80'  action='\/care\/wp-json\/wp\/v2\/pages\/11958' data-formid='80' >\n                        <div class='gform-body gform_body'><ul id='gform_fields_80' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_80_1\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_1\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_80_1'>\n                            \n                            <span id='input_80_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_80_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_80_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_80_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_80_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_80_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_80_2\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_2\"><label class='gfield_label gform-field-label' for='input_80_2' >Preferred first name\/nickname (as you would like it on your badge should you be accepted to the program):<\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_80_2' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_80_7\"  class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_7\"><label class='gfield_label gform-field-label' for='input_80_7' >Institutional\/work email:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_80_7' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_80_31\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_31\"><label class='gfield_label gform-field-label' for='input_80_31' >Personal email:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_80_31' type='text' value='' class='medium'  aria-describedby=\"gfield_description_80_31\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_80_31'>Please include an additional (i.e., non-institutional) email address you may be reached at.<\/div><\/li><li id=\"field_80_45\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_45\"><label class='gfield_label gform-field-label' for='input_80_45' >Preferred email for CRIT communications:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_45' id='input_80_45' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Institutional email' >Institutional email<\/option><option value='Personal email' >Personal email<\/option><\/select><\/div><\/li><li id=\"field_80_8\"  class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_8\"><label class='gfield_label gform-field-label' for='input_80_8' >Personal telephone:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_80_8' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_80_20\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_20\"><label class='gfield_label gform-field-label' for='input_80_20' >Degree(s) earned (e.g., MD, MPH):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_80_20' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_80_43\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_43\"><label class='gfield_label gform-field-label' for='input_80_43' >Residency program name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_80_43' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_80_42\"  class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_42\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Residency program mailing address:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_80_42' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_80_42_1_container' >\n                                        <input type='text' name='input_42.1' id='input_80_42_1' value=''    aria-required='true'    \/>\n                                        <label for='input_80_42_1' id='input_80_42_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_80_42_2_container' >\n                                        <input type='text' name='input_42.2' id='input_80_42_2' value=''     aria-required='false'   \/>\n                                        <label for='input_80_42_2' id='input_80_42_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_80_42_3_container' >\n                                    <input type='text' name='input_42.3' id='input_80_42_3' value=''    aria-required='true'    \/>\n                                    <label for='input_80_42_3' id='input_80_42_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_80_42_4_container' >\n                                        <input type='text' name='input_42.4' id='input_80_42_4' value=''      aria-required='true'    \/>\n                                        <label for='input_80_42_4' id='input_80_42_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_80_42_5_container' >\n                                    <input type='text' name='input_42.5' id='input_80_42_5' value=''    aria-required='true'    \/>\n                                    <label for='input_80_42_5' id='input_80_42_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_80_42_6_container' >\n                                        <select name='input_42.6' id='input_80_42_6'   aria-required='true'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_80_42_6' id='input_80_42_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_80_21\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_21\"><label class='gfield_label gform-field-label' for='input_80_21' >Residency program medical school affiliation, if any:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_80_21' type='text' value='' class='medium'  aria-describedby=\"gfield_description_80_21\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_80_21'>Write N\/A if there is none.<\/div><\/li><li id=\"field_80_40\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_40\"><label class='gfield_label gform-field-label' for='input_80_40' >Residency program hospital affiliation, if any:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_80_40' type='text' value='' class='medium'  aria-describedby=\"gfield_description_80_40\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_80_40'>Write N\/A if there is none. <\/div><\/li><li id=\"field_80_5\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_5\"><label class='gfield_label gform-field-label' for='input_80_5' >Chief resident specialty (i.e., internal medicine, family medicine, other - please explain)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_80_5' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_80_41\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_41\"><label class='gfield_label gform-field-label'  >Is your chief residency an additional resident year?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_80_41'>\n\t\t\t<li class='gchoice gchoice_80_41_0'>\n\t\t\t\t<input name='input_41' type='radio' value='Yes'  id='choice_80_41_0'    \/>\n\t\t\t\t<label for='choice_80_41_0' id='label_80_41_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_80_41_1'>\n\t\t\t\t<input name='input_41' type='radio' value='No'  id='choice_80_41_1'    \/>\n\t\t\t\t<label for='choice_80_41_1' id='label_80_41_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_80_10\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_10\"><h2 class=\"gsection_title\">Mailing Address<\/h2><\/li><li id=\"field_80_11\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_11\"><label class='gfield_label gform-field-label'  >Same as residency program address above?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_80_11'>\n\t\t\t<li class='gchoice gchoice_80_11_0'>\n\t\t\t\t<input name='input_11' type='radio' value='Yes'  id='choice_80_11_0'    \/>\n\t\t\t\t<label for='choice_80_11_0' id='label_80_11_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_80_11_1'>\n\t\t\t\t<input name='input_11' type='radio' value='No'  id='choice_80_11_1'    \/>\n\t\t\t\t<label for='choice_80_11_1' id='label_80_11_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_80_12\"  class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_12\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Mailing address:<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_80_12' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_80_12_1_container' >\n                                        <input type='text' name='input_12.1' id='input_80_12_1' value=''    aria-required='false'    \/>\n                                        <label for='input_80_12_1' id='input_80_12_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_80_12_2_container' >\n                                        <input type='text' name='input_12.2' id='input_80_12_2' value=''     aria-required='false'   \/>\n                                        <label for='input_80_12_2' id='input_80_12_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_80_12_3_container' >\n                                    <input type='text' name='input_12.3' id='input_80_12_3' value=''    aria-required='false'    \/>\n                                    <label for='input_80_12_3' id='input_80_12_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_80_12_4_container' >\n                                        <input type='text' name='input_12.4' id='input_80_12_4' value=''      aria-required='false'    \/>\n                                        <label for='input_80_12_4' id='input_80_12_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_80_12_5_container' >\n                                    <input type='text' name='input_12.5' id='input_80_12_5' value=''    aria-required='false'    \/>\n                                    <label for='input_80_12_5' id='input_80_12_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_80_12_6_container' >\n                                        <select name='input_12.6' id='input_80_12_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_80_12_6' id='input_80_12_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_80_18\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_18\"><label class='gfield_label gform-field-label' for='input_80_18' >Faculty mentor name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_80_18' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_80_36\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_36\"><label class='gfield_label gform-field-label' for='input_80_36' >Faculty mentor email:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_80_36' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_80_39\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_39\"><label class='gfield_label gform-field-label'  >Is your faculty mentor applying to attend CRIT with you?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_80_39'>\n\t\t\t<li class='gchoice gchoice_80_39_0'>\n\t\t\t\t<input name='input_39' type='radio' value='Yes'  id='choice_80_39_0'    \/>\n\t\t\t\t<label for='choice_80_39_0' id='label_80_39_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_80_39_1'>\n\t\t\t\t<input name='input_39' type='radio' value='No'  id='choice_80_39_1'    \/>\n\t\t\t\t<label for='choice_80_39_1' id='label_80_39_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_80_17\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_17\"><label class='gfield_label gform-field-label'  >Is your faculty mentor also your program director?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_80_17'>\n\t\t\t<li class='gchoice gchoice_80_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='Yes'  id='choice_80_17_0'    \/>\n\t\t\t\t<label for='choice_80_17_0' id='label_80_17_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_80_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='No'  id='choice_80_17_1'    \/>\n\t\t\t\t<label for='choice_80_17_1' id='label_80_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_80_30\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_80_30\"><label class='gfield_label gform-field-label' for='input_80_30' >Residency program director name:<\/label><div class='gfield_description' id='gfield_description_80_30'>Note: if you have already provided the residency program director's information above, you may leave these fields blank.<\/div><div class='ginput_container ginput_container_text'><input name='input_30' id='input_80_30' type='text' value='' class='medium'  aria-describedby=\"gfield_description_80_30\"    aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_80_37\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_37\"><label class='gfield_label gform-field-label' for='input_80_37' >Residency program director email:<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_80_37' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_80_58\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_58\"><label class='gfield_label gform-field-label' for='input_80_58' >Total number of residents in your residency program:<\/label><div class='ginput_container ginput_container_select'><select name='input_58' id='input_80_58' class='medium gfield_select'     aria-invalid=\"false\" ><option value='&lt;20 residents' >&lt;20 residents<\/option><option value='21-49 residents' >21-49 residents<\/option><option value='50-99 residents' >50-99 residents<\/option><option value='&gt;100 residents' >&gt;100 residents<\/option><\/select><\/div><\/li><li id=\"field_80_59\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_59\"><label class='gfield_label gform-field-label' for='input_80_59' >Percentage of time teaching:<\/label><div class='ginput_container ginput_container_select'><select name='input_59' id='input_80_59' class='medium gfield_select'     aria-invalid=\"false\" ><option value='&lt;20%' >&lt;20%<\/option><option value='21-40%' >21-40%<\/option><option value='41-60%' >41-60%<\/option><option value='61-80%' >61-80%<\/option><option value='&gt;80%' >&gt;80%<\/option><\/select><\/div><\/li><li id=\"field_80_49\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_49\"><label class='gfield_label gform-field-label' for='input_80_49' >Has your residency program participated in CRIT before?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_49' id='input_80_49' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='I don&#039;t know' >I don&#039;t know<\/option><\/select><\/div><\/li><li id=\"field_80_13\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_13\"><h2 class=\"gsection_title\">Other Information<\/h2><\/li><li id=\"field_80_15\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_15\"><label class='gfield_label gform-field-label' for='input_80_15' >Gender Identity<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_15' id='input_80_15' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Female' selected='selected'>Female<\/option><option value='Male' >Male<\/option><option value='Prefer to self describe' >Prefer to self describe<\/option><\/select><\/div><\/li><li id=\"field_80_46\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_46\"><label class='gfield_label gform-field-label' for='input_80_46' >If you selected &quot;Prefer to self describe,&quot; please specify here:<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_80_46' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_80_60\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_60\"><label class='gfield_label gform-field-label' for='input_80_60' >Pronouns<\/label><div class='ginput_container ginput_container_select'><select name='input_60' id='input_80_60' class='medium gfield_select'     aria-invalid=\"false\" ><option value='She\/her' >She\/her<\/option><option value='He\/his' >He\/his<\/option><option value='They\/them' >They\/them<\/option><option value='Prefer to self describe' >Prefer to self describe<\/option><\/select><\/div><\/li><li id=\"field_80_61\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_61\"><label class='gfield_label gform-field-label' for='input_80_61' >If you selected &quot;Prefer to self describe,&quot; please specify here:<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_80_61' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_80_44\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_44\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Race\/Ethnicity:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_80_44'><li class='gchoice gchoice_80_44_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.1' type='checkbox'  value='Black or African American'  id='choice_80_44_1'   aria-describedby=\"gfield_description_80_44\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_80_44_1' id='label_80_44_1' class='gform-field-label gform-field-label--type-inline'>Black or African American<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_80_44_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.2' type='checkbox'  value='American Indian or Alaska Native'  id='choice_80_44_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_44_2' id='label_80_44_2' class='gform-field-label gform-field-label--type-inline'>American Indian or Alaska Native<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_80_44_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.3' type='checkbox'  value='Asian'  id='choice_80_44_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_44_3' id='label_80_44_3' class='gform-field-label gform-field-label--type-inline'>Asian<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_80_44_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.4' type='checkbox'  value='Hispanic or Latino'  id='choice_80_44_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_44_4' id='label_80_44_4' class='gform-field-label gform-field-label--type-inline'>Hispanic or Latino<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_80_44_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.5' type='checkbox'  value='Native Hawaiian or Other Pacific Islander'  id='choice_80_44_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_44_5' id='label_80_44_5' class='gform-field-label gform-field-label--type-inline'>Native Hawaiian or or Other Pacific Islander<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_80_44_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.6' type='checkbox'  value='White'  id='choice_80_44_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_44_6' id='label_80_44_6' class='gform-field-label gform-field-label--type-inline'>White<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_80_44_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.7' type='checkbox'  value='Other'  id='choice_80_44_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_44_7' id='label_80_44_7' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_80_44'>Select all that apply.<\/div><\/li><li id=\"field_80_48\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_48\"><label class='gfield_label gform-field-label' for='input_80_48' >Please describe &quot;other&quot;:<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_80_48' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_80_62\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_62\"><label class='gfield_label gform-field-label'  >Are you a member of an underrepresented group (URG) in biomedical, clinical, behavioral or social science? are unsure if you would be considered as being a part of an Underrepresented Group, see below link for a full list. This is not an exhaustive list and we are continuously working to update it accordingly to be representative of all people in underrepresented groups.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_80_62'>\n\t\t\t<li class='gchoice gchoice_80_62_0'>\n\t\t\t\t<input name='input_62' type='radio' value='Yes'  id='choice_80_62_0'    \/>\n\t\t\t\t<label for='choice_80_62_0' id='label_80_62_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_80_62_1'>\n\t\t\t\t<input name='input_62' type='radio' value='No'  id='choice_80_62_1'    \/>\n\t\t\t\t<label for='choice_80_62_1' id='label_80_62_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_80_62'>https:\/\/diversity.nih.gov\/about-us\/population-underrepresented<\/div><\/li><li id=\"field_80_66\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_66\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Please specify<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_80_66'><li class='gchoice gchoice_80_66_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.1' type='checkbox'  value='Individual from racial and ethnic groups that have been shown by the National Science Foundation to be underrepresented in health-related sciences on a national basis'  id='choice_80_66_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_66_1' id='label_80_66_1' class='gform-field-label gform-field-label--type-inline'>Individual from racial and ethnic groups that have been shown by the National Science Foundation to be underrepresented in health-related sciences on a national basis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_80_66_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.2' type='checkbox'  value='Individual with disabilities, who are defined as those with a physical or mental impairment that substantially limits one or more major life activities'  id='choice_80_66_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_66_2' id='label_80_66_2' class='gform-field-label gform-field-label--type-inline'>Individual with disabilities, who are defined as those with a physical or mental impairment that substantially limits one or more major life activities<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_80_66_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.3' type='checkbox'  value='Individual from disadvantaged backgrounds (those who meet two or more of the disadvantaged background criteria listed on the above NIH website)'  id='choice_80_66_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_66_3' id='label_80_66_3' class='gform-field-label gform-field-label--type-inline'>Individual from disadvantaged backgrounds (those who meet two or more of the disadvantaged background criteria listed on the above NIH website)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_80_66_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.4' type='checkbox'  value='Prefer not to answer'  id='choice_80_66_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_66_4' id='label_80_66_4' class='gform-field-label gform-field-label--type-inline'>Prefer not to answer<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_80_70\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_70\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Have you ever visited the following in a professional context? (Check all that apply.)<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_80_70'><li class='gchoice gchoice_80_70_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.1' type='checkbox'  value='A mutual help or 12-step program (e.g., AA, NA, Learn to Cope)'  id='choice_80_70_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_70_1' id='label_80_70_1' class='gform-field-label gform-field-label--type-inline'>A mutual help or 12-step program (e.g., AA, NA, Learn to Cope)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_80_70_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.2' type='checkbox'  value='A substance use treatment facility only (e.g., detox, methadone maintenance)'  id='choice_80_70_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_70_2' id='label_80_70_2' class='gform-field-label gform-field-label--type-inline'>A substance use treatment facility only (e.g., detox, methadone maintenance)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_80_70_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.3' type='checkbox'  value='A harm reduction program (e.g., syringe service, naloxone distribution)'  id='choice_80_70_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_70_3' id='label_80_70_3' class='gform-field-label gform-field-label--type-inline'>A harm reduction program (e.g., syringe service, naloxone distribution)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_80_54\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_54\"><label class='gfield_label gform-field-label'  >Preferred T-shirt size (should you be accepted to the program):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_80_54'>\n\t\t\t<li class='gchoice gchoice_80_54_0'>\n\t\t\t\t<input name='input_54' type='radio' value='Men&#039;s x-small'  id='choice_80_54_0'    \/>\n\t\t\t\t<label for='choice_80_54_0' id='label_80_54_0' class='gform-field-label gform-field-label--type-inline'>Men's x-small<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_80_54_1'>\n\t\t\t\t<input name='input_54' type='radio' value='Men&#039;s small'  id='choice_80_54_1'    \/>\n\t\t\t\t<label for='choice_80_54_1' id='label_80_54_1' class='gform-field-label gform-field-label--type-inline'>Men's small<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_80_54_2'>\n\t\t\t\t<input name='input_54' type='radio' value='Men&#039;s medium'  id='choice_80_54_2'    \/>\n\t\t\t\t<label for='choice_80_54_2' id='label_80_54_2' class='gform-field-label gform-field-label--type-inline'>Men's medium<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_80_54_3'>\n\t\t\t\t<input name='input_54' type='radio' value='Men&#039;s large'  id='choice_80_54_3'    \/>\n\t\t\t\t<label for='choice_80_54_3' id='label_80_54_3' class='gform-field-label gform-field-label--type-inline'>Men's large<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_80_54_4'>\n\t\t\t\t<input name='input_54' type='radio' value='Men&#039;s x-large'  id='choice_80_54_4'    \/>\n\t\t\t\t<label for='choice_80_54_4' id='label_80_54_4' class='gform-field-label gform-field-label--type-inline'>Men's x-large<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_80_54_5'>\n\t\t\t\t<input name='input_54' type='radio' value='Men&#039;s xx-large'  id='choice_80_54_5'    \/>\n\t\t\t\t<label for='choice_80_54_5' id='label_80_54_5' class='gform-field-label gform-field-label--type-inline'>Men's xx-large<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_80_54_6'>\n\t\t\t\t<input name='input_54' type='radio' value='Women&#039;s small'  id='choice_80_54_6'    \/>\n\t\t\t\t<label for='choice_80_54_6' id='label_80_54_6' class='gform-field-label gform-field-label--type-inline'>Women's small<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_80_54_7'>\n\t\t\t\t<input name='input_54' type='radio' value='Women&#039;s medium'  id='choice_80_54_7'    \/>\n\t\t\t\t<label for='choice_80_54_7' id='label_80_54_7' class='gform-field-label gform-field-label--type-inline'>Women's medium<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_80_54_8'>\n\t\t\t\t<input name='input_54' type='radio' value='Women&#039;s large'  id='choice_80_54_8'    \/>\n\t\t\t\t<label for='choice_80_54_8' id='label_80_54_8' class='gform-field-label gform-field-label--type-inline'>Women's large<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_80_54_9'>\n\t\t\t\t<input name='input_54' type='radio' value='Women&#039;s x-large'  id='choice_80_54_9'    \/>\n\t\t\t\t<label for='choice_80_54_9' id='label_80_54_9' class='gform-field-label gform-field-label--type-inline'>Women's x-large<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_80_22\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_22\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >What are your plans upon completion of your chief residency?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_80_22'><li class='gchoice gchoice_80_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='Fellowship'  id='choice_80_22_1'   aria-describedby=\"gfield_description_80_22\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_80_22_1' id='label_80_22_1' class='gform-field-label gform-field-label--type-inline'>Fellowship<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_80_22_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.2' type='checkbox'  value='Clinician Educator'  id='choice_80_22_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_22_2' id='label_80_22_2' class='gform-field-label gform-field-label--type-inline'>Clinician Educator<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_80_22_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.3' type='checkbox'  value='Research'  id='choice_80_22_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_22_3' id='label_80_22_3' class='gform-field-label gform-field-label--type-inline'>Research<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_80_22_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.4' type='checkbox'  value='Full-time Clinical Practice'  id='choice_80_22_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_22_4' id='label_80_22_4' class='gform-field-label gform-field-label--type-inline'>Full-time Clinical Practice<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_80_22_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.5' type='checkbox'  value='Academic Medical Center Practice'  id='choice_80_22_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_22_5' id='label_80_22_5' class='gform-field-label gform-field-label--type-inline'>Academic Medical Center Practice<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_80_22_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.6' type='checkbox'  value='Private Practice'  id='choice_80_22_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_22_6' id='label_80_22_6' class='gform-field-label gform-field-label--type-inline'>Private Practice<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_80_22_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.7' type='checkbox'  value='Other'  id='choice_80_22_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_22_7' id='label_80_22_7' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_80_22'>Select all that apply.<\/div><\/li><li id=\"field_80_63\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_63\"><label class='gfield_label gform-field-label' for='input_80_63' >If you selected &quot;Fellowship,&quot; please specify here:<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_80_63' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_80_47\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_47\"><label class='gfield_label gform-field-label' for='input_80_47' >Please describe &quot;other&quot;:<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_80_47' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_80_26\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_26\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >How did you hear about the CRIT Program?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_80_26'><li class='gchoice gchoice_80_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='Previous CRIT Program attendee'  id='choice_80_26_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_26_1' id='label_80_26_1' class='gform-field-label gform-field-label--type-inline'>Previous CRIT Program attendee<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_80_26_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.2' type='checkbox'  value='Faculty at my institution'  id='choice_80_26_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_26_2' id='label_80_26_2' class='gform-field-label gform-field-label--type-inline'>Faculty at my institution<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_80_26_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.3' type='checkbox'  value='Brochure or postcard advertising the program'  id='choice_80_26_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_26_3' id='label_80_26_3' class='gform-field-label gform-field-label--type-inline'>Brochure or postcard advertising the program<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_80_26_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.4' type='checkbox'  value='Internet search'  id='choice_80_26_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_26_4' id='label_80_26_4' class='gform-field-label gform-field-label--type-inline'>Internet search<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_80_26_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.5' type='checkbox'  value='Email from the program'  id='choice_80_26_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_26_5' id='label_80_26_5' class='gform-field-label gform-field-label--type-inline'>Email from the program<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_80_26_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.6' type='checkbox'  value='Other (describe below)'  id='choice_80_26_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_26_6' id='label_80_26_6' class='gform-field-label gform-field-label--type-inline'>Other (describe below)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_80_27\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_27\"><label class='gfield_label gform-field-label' for='input_80_27' >Please describe &quot;other&quot;:<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_80_27' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_80_64\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_64\"><label class='gfield_label gform-field-label' for='input_80_64' >Please specify:<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_80_64' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_80_53\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_53\"><h2 class=\"gsection_title\">Application Essay &amp; Letters<\/h2><\/li><li id=\"field_80_75\"  class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_75\"><label class='gfield_label gform-field-label' for='input_80_75' >Please provide a statement of 500 words or less describing your motivation and goals for participating in the CRIT Program. Discuss your interest in addiction medicine. Describe how you plan to disseminate the knowledge and skills gained at CRIT to your learners during your chief residency, as well as your plans for integrating addiction medicine into your residency program&#039;s curriculum. Copy-paste this into the box below.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_75' id='input_80_75' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_80_68\"  class=\"gfield gfield--type-fileupload field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_68\"><label class='gfield_label gform-field-label' for='input_80_68' >Please provide a letter of support from your residency program director that includes a statement of the expected percentage of your time that will be spent teaching during your chief resident year.<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='104857600' \/><input name='input_68' id='input_80_68' type='file' class='medium' aria-describedby=\"gfield_upload_rules_80_68 gfield_description_80_68\" onchange='javascript:gformValidateFileSize( this, 104857600 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_80_68'>Accepted file types: doc, docx, pdf, Max. file size: 100 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_80_68'><\/div><\/div><div class='gfield_description' id='gfield_description_80_68'>If you don't have this ready at the time of application submission please have it emailed to Jules Canfield at jules.canfield@bmc.org prior to the application deadline. <\/div><\/li><li id=\"field_80_69\"  class=\"gfield gfield--type-fileupload field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_69\"><label class='gfield_label gform-field-label' for='input_80_69' >Please provide a letter of support from a faculty mentor who will support the integration of addiction medicine into your institution&#039;s curriculum. Note: if your residency director is also your mentor, only one letter is required.<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='104857600' \/><input name='input_69' id='input_80_69' type='file' class='medium' aria-describedby=\"gfield_upload_rules_80_69 gfield_description_80_69\" onchange='javascript:gformValidateFileSize( this, 104857600 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_80_69'>Accepted file types: doc, docx, pdf, Max. file size: 100 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_80_69'><\/div><\/div><div class='gfield_description' id='gfield_description_80_69'>If you don't have this ready at the time of application submission please have it emailed to Jules Canfield at jules.canfield@bmc.org prior to the application deadline. <\/div><\/li><li id=\"field_80_50\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_50\"><h2 class=\"gsection_title\">Curriculum Vitae<\/h2><\/li><li id=\"field_80_25\"  class=\"gfield gfield--type-fileupload gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_25\"><label class='gfield_label gform-field-label' for='input_80_25' >Please upload your curriculum vitae (CV) as a PDF here.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='104857600' \/><input name='input_25' id='input_80_25' type='file' class='medium' aria-describedby=\"gfield_upload_rules_80_25\" onchange='javascript:gformValidateFileSize( this, 104857600 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_80_25'>Accepted file types: pdf, Max. file size: 100 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_80_25'><\/div><\/div><\/li><li id=\"field_80_76\"  class=\"gfield gfield--type-section gsection bu_google_recaptcha_section field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_76\"><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_80_77\"  class=\"gfield gfield--type-html bu_google_recaptcha gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_80_77\"><div class=\"g-recaptcha\" data-sitekey=\"6LeGxkEjAAAAAK4nzHZn3a_6jB2ELSN935WrVBfC\"><\/div><\/li><\/ul><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_80' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_80\"]){return false;}  window[\"gf_submitting_80\"]=true; 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