NOTE: Applications will be accepted only for students who are fourth year students in LCME Schools, or final year students in foreign medical schools. All visiting students must meet certain health and immunization requirements. International students are limited by NY State Law to 12 weeks of clerkships.
TO BE COMPLETED BY STUDENT: Please complete the application form for desired electives. The application must be accompanied by a check for $100.00 payable to The University of Rochester School of Medicine and Dentistry to begin the application process. Please print or type this form.
Name
Address
City State Zip Country
Telephone Number Year Level
e-mail address: ____________________________________________________
Gender: Male Female Date of Birth:
Signature
List below the elective desired. List additional options in case you cannot be scheduled for your first choice and/or dates. Electives can be found on the website at http://www.urmc.rochester.edu/smd/mdregistrar/ and clicking Clinical Programs 2001-2002.
COURSE ID ELECTIVE TITLE #WEEKS
1.
2.
3.
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TO BE COMPLETED BY THE DEAN
OF STUDENTS, or
comparable official, of the medical students school: The student named above is in good standing
at this institution and is approved to take this elective(s).
I have enclosed a letter of recommendation.
The student (will) (will not) be covered by basic ambulatory
health care. If not covered, the student
must carry The University of Rochesters health care at approximately $30.00
per month. Malpractice insurance (does)
(does not) cover the student while away from this school. The student (will) (will not) pay tuition at
this school during the extramural period.
Academic credit toward the M.D. degree (will) (will not) be awarded upon
the receipt of a passing grade. An
evaluation of this elective (will) (will not) be required.
Name
Title
Signature
School
Address
City
State Zip Date