Dates to Apply: Early or late applications will not be accepted. University of Ottawa January 16 to 30, 2024 Queen's University January 1 to 15, 2024 Lakeridge December 4 to 8, 2023 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 * - Select -MaleFemale Information is required for accommodation purposes. Stream * - Select -AnglophoneFrancophone Student Number * Current Address Street * City * Province/Territory * - Select -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code * Please use the format xxx xxx Is your current address the same as your permanent address? * - Select -YesNo Permanent Address Street City Province/Territory - None -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Please use the format xxx xxx School Information Medical School * - Select -OttawaQueen'sLakeridge Placement Information Classmates you wish to be placed with (maximum 5 students per group) ***ERMEP cannot guarantee your groups will be kept together.*** Comments Comments Do you have a vehicle? Only indicate YES if you have your own vehicle during community week. A vehicle is highly recommended for community week. * - Select -yesno Are you willing to transport other students? * - Select -yesno Number of students you can transport - None -123456 Will you require accomodations? * - Select -yesno 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? * - Select -yesno Cancellation PolicyThe 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 learner 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 * I agree to the Cancellation Policy What code is in the image? * Enter the characters shown in the image.