Family Medicine Underrepresented in Medicine (URiM) Student Elective Scholarship form

Program Description

This rotation is intended to give medical students from other institutions the opportunity to experience the exceptional training offered at Memorial Hospital of South Bend. This scholarship offers a stipend for travel and living expenses during your time here.

Eligibility:

Applicants are eligible if they: a) self-identify as being a member of a traditionally underrepresented racial/ethnic minority group, and b) if the expense of travel/lodging without the scholarship would cause economic hardship.

Legal Name*
First Middle Last
Preferred Name
First Last
Phone*
Email*
Name of Medical School*
Medical School Contact Information
Medical School Contact*
First Last
Phone*
Email*
Start Date*
Date Format: MM slash DD slash YYYY
Graduation Date*
Date Format: MM slash DD slash YYYY
Does your medical school have any specific requirements for this rotation?
- Yes
- No
Medical School Requirements
Do you need a J1 Visa for medical residency?*
- Yes
- No
Do you have dietary restrictions?
- Yes
- No
Special Diet Needs
Program Questions
What draws you to the specialty of family medicine?*
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?*
Housing
Please note: the student is responsible for finding their own housing during this rotation.
Eligibility*
By checking this box, I confirm I meet eligibility criteria for this scholarship.

Family Medicine Underrepresented in Medicine (URiM) Student Elective Scholarship form

Program Description

Eligibility:

Medical School Contact Information

Program Questions

Housing