Student Information Form for Incoming Medical Students

Fields denoted by an asterisk (*) are required.

First (Given) Name
Last Name
Known-By (if different from Given First Name)
Campus

Campus London Campus Windsor Campus Undeclared Campus
Email Address
Cell Phone Cell Phone - ### - ### ####
Western Student Number
Permanent Home Address Permanent Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Emergency Contact
First Name:
Relationship:
Last Name:
Phone Number: Phone Number: - ### - ### ####
Academic Accommodation and/or Personal Support Needs

Western is committed to achieving barrier free accessibility for persons with disabilities studying, visiting and working at Western. The University will take all reasonable steps to ensure accommodation specific to an individual’s needs is provided in a timely and effective way. For more information about Western’s commitment to accessibility please visit the Accessibility Western University website

If you require academic accommodations during your undergraduate dental education with Western, please contact Western’s Accessible Education Office to discuss the academic accommodation you require: see the Academic Accommodation webpage for information.
If there are conditions or situations that you anticipate will affect your medical studies or that you may need support for, please identify them here. This information will be held in strict confidence.
The Doctor of Medicine Program is a full-time program and classes can be scheduled from Monday to Friday, 8am -9 pm. Schedules can change through the year. If you have ongoing personal circumstances or spiritual commitments that may be impacted, please identify these here or let us know if we can contact you about this.
If you wish to inform the Learner Experience Office of anything further, please use the space below.

Student Information Form for Incoming Medical Students

Student Information Form for Incoming Medical Students

Emergency Contact

Academic Accommodation and/or Personal Support Needs