Learner Travel Expense Form

Fields denoted by an asterisk (*) are required.

Personal Information
Name
Street Address
Apartment/Unit Number

(if not applicable please add N/A)
City
Province
Maximum of 2 characters allowed. Currently Entered: 2 characters.
Postal Code
Must be 7 characters. Currently Entered: 0 characters.
e.g. A1A 1A1
Country
Telephone Telephone - ### - ### ####
Email
Are you a Sculich Medicine & Dentistry learner?

Are you a Sculich Medicine & Dentistry learner? Yes No
Learner Type:

Learner Type: Postgraduate Undergraduate
Home Program or Department:
Campus or Academic Home Base location:
Home University
Rotation Information
Rotation type:

Rotation type: Postgraduate Undergraduate
Please choose one of the following:

Please choose one of the following: Core Elective
Please select one of the following programs:

Please select one of the following programs: Preclerkship Summer Elective Summer Research Elective MedLINCS (please list MedLINCs as your rotation specialty) Clerkship 4th Year Elective Discovery Week (please list Discovery Week as your rotation specialty)
Rotation Location:
Rotation Specialty:
Name of Preceptor:
Rotation Start Date: Rotation Start Date: / MM / DD YYYY
Rotation End Date: Rotation End Date: / MM / DD YYYY
Travel Details:
Did you have accommodations provided by Schulich Distributed Education during your community rotation?

Did you have accommodations provided by Schulich Distributed Education during your community rotation? Yes No
One return trip for rotation is provided. Please provide details of any travel required for educational purposes to apply for additional funding. Example, May 14 attend academic half day.
Please identify the number of round trips you made commuting during your community rotation. Example, 15 round trips from London to Stratford.
Distance traveled for one round trip:
Total number of Kilometers traveled:
Receipt Upload

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By clicking the button below you are confirming all information submitted on this form is accurate and true. I AGREE

Learner Travel Expense Form

Learner Travel Expense Form

Personal Information

Rotation Information

Travel Details: