Senior Student Elective Application

Posted September 24th, 2007 by admin

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):

Will you have personal transportation? :

Will you need housing? :

(Note: We have no housing resources in Madison.)

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?:

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