Second Year Summer Elective Application Form

Second Year Summer Elective Application Form Eastern Regional Medical Education Program (ERMEP)

Nursing homes in Ontario are homes to people who frequently have multiple and complex medical problems and needs. Most of these people are pleased to see medical students and contribute to their education; thus providing a wonderful opportunity for students to see, examine, and help people with significant pathology (strong physical signs/findings).
This elective is serving to consolidate the students' skills in these vital areas of clinical history taking, physical examination, and management program development.
This elective is open to all 2nd medical students (successfully completed their 2nd year). This placement is for four weeks. Some communities participating in this elective require that the student has a vehicle.
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: *

Placement Information

Preferred Location: *

Expectations of learning experience

Goals:

Hobbies and/or Interests:

Do you have a vehicle?: *

Will you require accomodations?: *

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?: *

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: *

Second Year Summer Elective Application Form

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