Application for Medical Student Clerkship

In addition to this application, we require a letter from your medical school confirming that:

1. You are a student in good standing.
2. You are covered by your school’s malpractice insurance.
3. Your vaccinations and PPD status are up to date.
4. You have completed mandatory OSHA training through your school.

All fields are required.

Personal Information

1. Name
2. Address
3. Address
4. City
5. State - select - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
6. ZIP code

1. Phone number
2. Mobile/Pager number
3. Fax number

1. E-mail address

Education

Pre-medical Education

1. Institution
2. Dates

   1. From
      month January February March April May June July August September October November December year 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
   2. To
      month January February March April May June July August September October November December year 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
3. Major

Medical Education

1. Institution
2. Dates

   1. From
      month January February March April May June July August September October November December year 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
   2. To
      month January February March April May June July August September October November December year 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Clerkship

1. Desired clerkship

   • General Family Medicine
   • Sub-internship in Inpatient Family Medicine
2. Desired dates

   1. First choice
      month January February March April May June July August September October November December year 2008 2009 2010 2011 2012 2013
   2. Second choice
      month January February March April May June July August September October November December year 2008 2009 2010 2011 2012 2013
   3. Third choice
      month January February March April May June July August September October November December year 2008 2009 2010 2011 2012 2013
3. Please summarize your reasons for applying and goals for the clerkship

Submit Application

• Student Clerkships

• Clinical Clerkship in Family Medicine
• Subinternship in Inpatient Family Medicine
• Clerkship Application Form