Family Medicine Elective Request Form
Family Medicine Elective Request Form
Fields denoted by an asterisk (
*
) are required.
Resident's Name
Resident's Name
*
First
Last
Email Address
*
Rotation Details
Rotation Name
*
Preceptor's Name
Preceptor's Name
First
Last
If preceptor name is known, please provide preceptor email address
Preceptor's Phone Number
Preceptor's Phone Number
-
###
-
###
####
Rotation Start Date
Rotation Start Date
*
/
MM
/
DD
YYYY
Rotation End Date
Rotation End Date
*
/
MM
/
DD
YYYY
Does your Preceptor have an active appointment with an Accredited Academic Institution?
Active Appointment?
*
Does your Preceptor have an active appointment with an Accredited Academic Institution?
Active Appointment?
Yes
No
Location of Rotation
*
Schulich Medicine Distributed Education Region
Ontario-Outside Schulich Medicine Distributed Education Region
Other Province
International
Rotation Address
*
Hospital Affiliation
*
Good Standing Letter Required?
*
Good Standing Letter Required?
Yes
No
Please enter the name, address, fax & email of recipient of the letter:
Recipient's Name
Recipient's Name
*
First
Last
Recipient's Address
*
Recipient's Fax
Recipient's Fax
-
###
-
###
####
Recipient's Email Address
*
Rotation Objectives
*