Community Week Application

Community Week Application Form

Eastern Regional Medical Education Program (ERMEP)

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 #:

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: *

Placement Information

Preferred size of Community:

Classmates you wish to be placed with:

***ERMEP cannot guarantee your preferred location or the classmates you wish to be placed with.***

Special Interests:

Expectations of learning experience

Goals:

Hobbies and/or Interests:

Do you have a vehicle?: *

yes

Are you willing to transport other students?: *

yes

Number of students you can transport:

Will you require accomodations?: *

yes

Do you have any pet allergies? (Please state):

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

yes

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: *

Community Week Application

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