Chief Residents Program Enrollment Form

2025 APDIM Chief Residents Program

Enrollment Form

(through June 30, 2025)

Chief Residents who registered for the 2024 APDIM Chief Residents Meeting are automatically enrolled in the academic year 2025 Chief Residents Program and do not need to complete this form.

There is no fee to enroll in the APDIM Chief Residents Program.
Enrollment is open to all academic year 2025 (July 1, 2024 to June 30, 2025) chief residents.

First Name *

Middle Initial

Last Name *

Suffix 1 *

Suffix 2

Residency Program Name *

Institution *

Program Director's Name *

Work Address 1 *

Work Address 2

Work City *

Work State/Province *

Work ZIP Code *

Work Phone *

Work Fax

Email Address *

Term as Chief Medical Resident (ex. July 1, 2024 - June 30, 2025) *

How many chief residents serve in your residency program? *