Hacking Dermatology Participant Application

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If you are interested in being considered to be a participant at Hacking Dermatology on September 13-15, 2019, please complete this application. Applications will be considered on a rolling basis and you will be notified within 2 weeks of your application being submitted. Participants will join teams and compete in the hackathon activities.

If you are interested in being a mentor, who shares expertise and guidance with multiple teams, please fill out the mentor application (https://forms.gle/1Vo5Z2G72AxsDNV56).

Email *

First Name *

Last Name *

Please list your preferred credentials:

What is your age range? *

<17

18-22

23-29

30-39

40-49

50-59

60-69

>70

Please tell us which city, state, and country you will be coming from? *

Which of the following best describes you? *

Undergraduate student

Graduate student

Post-doc

Professional

Other:

What is your school/company affiliation? *

What is your current title? *

What best describes your background? Examples: Physician/Dermatology, Scientist/Data Scientist, or Designer/Industrial Design *

Provider/Clinician - Dermatology Specific (Physician, Nurse Practitioner, etc.)

Provider/Clinician - Non-dermatology (Physician, Nurse Practitioner, Physical Therapist, EMT, etc.)

Designer (Product, Graphic, Print, etc.)

Software Professional (Developer, IT Professional, etc.)

Engineer (Electrical, Mechanical, Biological, Chemical, etc.)

Data Engineer / Data Scientist

Scientist (Life Sciences, Physics, etc. )

Writer / Journalist / Photographer / Media Specialist

Patient / Patient's Family

Other

Required

Can you commit to attending all three days on September 13-15, 2019? *

Yes

What is your experience in innovation / hackathons / healthcare / dermatology (if any) and what are some relevant skill sets/prior experience? *

Do you have any preliminary ideas you’d like to work on during the hackathon? This is NOT a prerequisite. * *

Yes

Please tell us the title of your idea/project, the general idea, goals, and data sets/resources needed to work on project.

How did you hear about this event? *

MIT Hacking Medicine newsletter/social media

Hacking Dermatology newsletter/social media

Online advertisement

Print flyer

Other:

Required

Comments / Questions / Concerns?

When you attend the hackathon and/other other related events, you will enter an area where photography, audio, and video recording may be taken and where members of the media may be present to cover the event. By attending this event, you consent to photography, audio, and video recording and its release, publication or reproduction to be used in the future. Do you acknowledge this? *

Yes

A copy of your responses will be emailed to the address you provided.

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