Medical Student Application

* First Name:

Middle Initial:

* Last Name:

* Gender:

Male

Female

* Email Address:

* Phone Number:

* Address:

* City:

* State:

* Zip Code:

* Medical School Name:

* Medical School Location (City and State, or Country):

* Expected Med School Graduation:

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* Current Med School Year:

If a MS3, indicate completed rotations from the list:

Inpatient Medicine (IM)

Outpatient Primary Care (Clinic)

Pediatrics (Peds)

OB/GYN (OB)

Family Medicine

What do you hope to learn from this externship?

2-week and 4-week externship programs run year-round. Please indicate your preferred externship start dates and 2-week or 4-week program participation:

* Program 1st Choice Start Date:

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* 1st Choice Program Length:

2 Weeks

4 Weeks

Program 2nd Choice Start Date:

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2nd Choice Program Length:

2 Weeks

4 Weeks

Program 3rd Choice Start Date:

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3rd Choice Program Length:

2 Weeks

4 Weeks

Do you have any special needs we should know about?

Will you be requesting any time off during the Externship?

Please Read the Following Terms Carefully. Select Each Checkbox If You Agree:

I understand that proof of Malpractice Coverage is mandatory if I am accepted.

I hereby certify that all of the information listed on this form is true and complete. I understand that any false, incomplete or misleading information given by me on this application is sufficient cause for rejection. I also understand and agree that any false, incomplete or misleading information discovered on this application at any time after I begin the Externship Program may result in my dismissal.

I have read and consent to the above TERMS and CONDITIONS of the application in its entirety. I further recognize that checking the adjoining box constitutes my Electronic Signature to this agreement.

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