Learner Accommodation Request Form - Distributed Education Network

Fields denoted by an asterisk (*) are required.

Name Name First Last
Email
Academic Home Base
Cell Phone Cell Phone - ### - ### ####
Gender

Gender Male Female
The personal information on this form is collected under the authority of the University of Western Ontario Act, 1982. The information is collected for the purpose of scheduling community accommodation. For further information about this collection, please contact the Administrative Coordinator, Distributed Education, Schulich School of Medicine & Dentistry, The University of Western Ontario, suite 225, 100 Collip Circle, London, ON; 519-858-5152.
Rotation Start Date Rotation Start Date / MM / DD YYYY
Rotation End Date Rotation End Date / MM / DD YYYY
Arrival Date Arrival Date / MM / DD YYYY
Departure Date Departure Date / MM / DD YYYY
Rotation Location
Rotation Type

Rotation Type Postgraduate Undergraduate
Please choose one of the following:

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

Please select one of the following programs: Preclerkship Summer Elective Summer Research Elective MedLINCS (please select family medicine as your rotation specialty) Clerkship 4th Year Elective
Rotation Specialty
Is this a Family Medicine Postgraduate Horizontal Rotation?

Is this a Family Medicine Postgraduate Horizontal Rotation? Yes No
Will you have access to a vehicle during this rotation?

Will you have access to a vehicle during this rotation? Yes No
Additional Information you would like to tell us:
I have reviewed and agree to the Accommodation Arrangements listed at the top of this form.

I have reviewed and agree to the Accommodation Arrangements listed at the top of this form. I agree