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

Last Name: *

First Name: *

Preferred First Name:

E-mail Address: *

(Please use your University e-mail address)

Phone #: * Please use the format (xxx) xxx-xxxx

Cell/Mobile #: Please use the format (xxx) xxx-xxxx

Gender: *

Stream: *

Current Address

Street: *

City: *

Province/Territory: *

Postal Code: * Please use the format xxx xxx

Permanent Address

Same as Current Address:

Street:

City:

Province/Territory:

Postal Code: Please use the format xxx xxx

School Information

Medical School: *

Student Number: *

Current Status: *

Status at time of rotation: *

Placement Information

Rotation Information: *

Rotation dates: * From

Rotation dates: * To

Length of rotation (No of weeks): *

Preferred Communities:

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.

Preferred preceptor:

Special interests:

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

Do you give ERMEP permission to choose a location if your choices are not available: *

Do you have a vehicle?: *

Will you require accomodations?: *

Do you have any pet allergies? : *

Does ERMEP have your permission to use your photograph in published articles, website, newsletters, flyers, posters, brochures and presentation materials?: *

Expectations of learning experience

Goals:

Hobbies and/or Interests:

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.

Cancellation Policy Agreement: *

Clerks Application Form

Quicklinks

Events

~ Copyright 2009 ermep.com ~ created by Sébastien Bacharach ~ Perth Computer Plus ~ Login ~