Advisor Request Form

Posted September 24th, 2007 by admin

Please use this form if you are a medical student interested in being matched with an advisor in Family Medicine.

If you have any questions or comments, feel free to call 608-263-1334 or email omse.coordinator@fammed.wisc.edu.

This form will be evaluated and an advisor will be assigned to you.

Name: *

Email: *

Street Address:

City:

State:

Zip Code:

My top three choices for an advisor are:

Current Medical School Year:

I'd prefer an advisor who has a special interest in:

(i.e. research, international health, mph, women's health, substance abuse, etc.)

Dates you know you will NOT be in Madison during the advising year:

Utilities