Senior Student Elective Application

Directions: Please respond briefly to all of the following questions.

Section One: Applicant Information

Name: *

Age:

Sex:

School Address:

Permanent Address:

Phone Number:

Email: *

Med School:

Elective Requested:

Dates Requested:

Second Choice:

Clinic Preferred (If Any):

Housing & Transportation Policy

Upon acceptance of an Elective through the Department of Family Medicine, it is understood that housing and transportation are the sole responsibility of the student.

I understand I will be responsible for my own housing and transportation: *

Yes

Please list all prior elective experience. (Include specialities and whether rotation(s) was in hospital or clinic-based):

Are you conversant in any languages other than English? (Please indicate which languages):

Please comment on your experience with disadvantaged and underserved patients:

Section Two: Questions

1. What are your plans for the future? :

Please include type of residency, type of practice, area in which you plan to settle, size of community, solo or group, size of group, etc

2. What are your specific learning goals for this experience?:

3. How does this requested elective fit in with your overall plan for your senior year?:

Section Three: Biography

Please provide a short bio-sketch that, if accepted for rotation, will be posted on the DFM Intranet and clinical rotation site. Please comment regarding why you are interested in this rotation site(s), any special interests or hobbies, and personal background.

Bio-sketch paragraph:

Please attach a photo of yourself:

(gif, jpg, or png are accepted. Max file size is 4MB)

Updated: November 09, 2010 by admin

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Senior Student Elective Application

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