Family Medicine In-Depth Elective Medical Student Rotation Application

About this rotation

This rotation is intended to be an audition rotation for those medical students interested in pursuing a family medicine residency. Medical student applications will be considered based on many factors including their eligibility to apply to the residency program. Of note, our residency program does not sponsor visas of any kind.

Name
First Last
Phone
Email
Education Questions
Name of Medical School
Medical School Contact Information
Name
First Last
Phone
Email
Start Date
Date Format: MM slash DD slash YYYY
Graduation Date
Date Format: MM slash DD slash YYYY
Please explain any gaps or extended time away from medical school:
Have you ever been on academic probation or a remediation program? If so, please explain.
Does your medical school have any specific requirements for this rotation?
Do you need a J1 Visa for medical residency?
- Yes
- No
Do you have any dietary restrictions?
Program Questions
What specialty will you pursue?
How did you hear about our program?
Why do you want to do a rotation at Memorial Hospital?
What dates do you have available for this rotation?
To help us select the best time of year for a rotation, several date fields have been provided. The text box provided here is for general comments related to your provided dates.
Date
Date Format: MM slash DD slash YYYY
Date
Date Format: MM slash DD slash YYYY
Date
Date Format: MM slash DD slash YYYY
Housing
The student is responsible for finding his/her own housing during this rotation.
USMLE/COMLEX Scores
Step 1 or Level 1 Exam Results
- Pass
- Fail
- Not Yet Taken
USMLE Step 2 CK/ COMLEX Level 2
If not yet completed, indicate Not Taken at this time.
USMLE Step 3/ Comlex Level 3
If not yet completed, indicate Not Taken at this time.

Family Medicine In-Depth Elective Medical Student Rotation Application

About this rotation

Education Questions

Medical School Contact Information

Program Questions

Housing

USMLE/COMLEX Scores