Summer Externship Application

Attention: We are no longer accepting applications until March 2009

Please respond briefly to all of the following questions.

Contact Information

Name: *

Phone Number:

E-mail Address: *

Address at School:

Permanent Address:

Questions

1. Why would you like to participate in the Family Physicians Summer Externship Program?:

2. What specific medical activities and procedures do you hope to participate in or observe during the externship?:

3. What ancillary activities of a family physician do you hope to experience during the externship?:

(community involvement, nursing home visits, etc.)

4. What do you hope to get out of this experience for your personal and professional development?:

5. Are there issues the committee will need to take into consideration when reviewing this application?:

(distance to site, earlier or later availibility, travel plans, etc.)

6. Do you have any special interests you would like us to be aware of?:

7. What are your top three preceptor preferences?:

(This is just to help get an idea of where you're interested in going.)

Stipulations

Note: The following stipulations only become effective when you have agreed to participate with a physician of your choice.

Stipulations (please read):
If I am selected to participate in the lottery and subsequently matched to a family physician of my choice, I understand that I am committed to completing the eight-week Externship program. I also understand that I will receive one-half of the stipend on June 30th and the remainder on July 31st, contingent upon the Academy office receiving my evaluation three days prior to that date. After July 31st, the Academy will send the remaining stipend after receiving the evaluation form.

Please note:
In order to be eligible for the program, participants are required to submit an evaluation and essay at the conclusion of the summer extern experience before receiving the final stipend. Four essays are selected to receive $500 each.

Membership with the American Academy of Family Physicians/Wisconsin Academy of Family Physicians is also required. Wisconsin AFP pays for student membership dues. (Go to http://www.aafp.org/join.xml to submit a member application.)

Agreement:

Yes, I understand and agree to the stipulations listed above should I be selected.

Updated: March 09, 2009 by admin

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Summer Externship Application

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