Clerks Application Form

Clerks Application Form - Eastern Regional Medical Education Program (ERMEP)

IMPORTANT - ERMEP requires a current photograph and a University Letter of Standing & Liability stating that you are a medical student in good standing at the university and you are covered by the university's liability insurance for the duration of this elective.

Personal Information

(Please use your University e-mail address)

Please use the format (xxx) xxx-xxxx
Please use the format (xxx) xxx-xxxx
Current Address
Please use the format xxx xxx
Permanent Address
Please use the format xxx xxx
School Information
Placement Information
From
To

Please choose up to three locations from the following list and enter them above:
Alexandria, Almonte, Arnprior, Bancroft, Barry's Bay, Belleville, Brockville, Calabogie, Carleton Place, Carp, Cornwall, Deep River, Finch, Hawkesbury, Kemptville, Lanark, Lansdowne, Madoc, Merrickville, Morrisburg, Napanee, Pakenham, Pembroke, Perth, Petawawa, Picton, Plantagenet, Renfrew, Rockland, Russell,Sharbot Lake, Smiths Falls,
South Mountain, St. Isidore, Sydenham, Verona, Winchester.

Please choose your special interests, if any, from the following list and enter them above: Family Practice, Anaesthesia, ER, OBS/gyn, General Surgery

Expectations of learning experience
Cancellation Policy

The Eastern Regional Medical Education Program [ERMEP] along with the Distributed Medical Education [DME] considers it unprofessional to cancel a rotation once a preceptor is confirmed. ERMEP considers it a breach of professionalism when the student cancels without a valid reason less than four weeks from the start date of the rotation.  ERMEP will then report this to the schools and ask that they deal with this as unprofessional behavior.  It is important to recognize that preceptors are often very annoyed by late changes due to their scheduling requirements.

Accommodation cancellations must be made through ERMEP a minimum of four weeks prior to placement start date.
By submitting this application, I agree to abide by all of ERMEP policies and confirm that I have not applied to any other Networks. I understand that once the Eastern Regional Medical Education Program has contacted me with the name of a preceptor, it is unprofessional for me to cancel the rotation.

I acknowledge that ERMEP will notify my school of any unprofessional behaviour.