Gold Foundation: White Coat Ceremony Pin Application Form

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White Coat Ceremony Pin Application Form

School's Name
Street Address
City, State, Zip	City: State: Zip:
Contact Person Name	Title:
Telephone	Area Code Number
Fax Number	Area Code Number
E-mail Address
Proposed Date of this year's White Coat Ceremony:
How many years has your school been holding a White Coat Ceremony?
Number of Students in Class:
Location and site capacity for Ceremony:	Location Capacity
Do you recite/discuss an oath?	Yes no If so, which one (Hippocrates, Maimonides, student-written...)
How are students cloaked in white coats?
Keynote Speaker	Speaker Name Brief Biography
Do you hold a reception following WCC?	yes no
Additional Components	Describe any additional components of your school's WCC which might be of interest to other schools.
By submitting this application I agree to acknowledge in all WCC printed materials that the Arnold P. Gold Foundation provided the gift of the Humanism in Medicine Lapel Pins to each entering medical student participating in the White Coat Ceremony. Agree Disagree