Clerks Application Form | ERMEP - Eastern Regional Medical Education Program

All rotations must be a minimum of 4 consecutive weeks to be accepted, set up, and funded by ERMEP.

We do not accept 2-week electives.

Regarding 3rd Year Core FM and 4th Year Elective Rotations…preferred community/preceptor suggestions cannot be guaranteed. You will be placed where an available preceptor is located. If you do not have a vehicle, this will be taken into consideration. A vehicle is highly recommended so all ERMEP communities can be considered.

During COVID, ERMEP is working from a reduced preceptor availability list.

Thank you for your understanding.

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 *

Information is required for accommodation purposes.

Stream *

Student Number *

Current Address

Street *

City *

Province/Territory *

Postal Code * Please use the format xxx xxx

Is your current address the same as your permanent address? *

Permanent Address

Street

City

Province/Territory

Postal Code Please use the format xxx xxx

School Information

Medical School *

Current Status *

Status at time of rotation *

Placement Information

Rotation Information *

Rotation dates from *

Month

Day

Year

Rotation dates to *

Month

Day

Year

Length of rotation (No of weeks) *

Preferred Communities

Please choose up to three locations

Preferred preceptor

Special interests

Please choose your special interests, if any.

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? (Please state)

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

Expectations of learning experience

Comments

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 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

To prevent automated spam submissions leave this field empty.

What code is in the image? *

Enter the characters shown in the image.