Pediatric Preceptorship Student Application

First Name

Last Name

Date of Birth

Gender

Male Female

Married?

Yes No

Do you speak Spanish?

Yes No

Do you speak other languages? If yes, list below

Whre did you grow up?

Rural Urban Other

Please list your favorite hobbies and extracurricular activities below.

Contact Information:

Address

City

State

Zip

Phone

Mobile

School Email

Personal Email

In case of Emergency:

Contact Name

Phone

Mobile

Do you have any physical limitations or medical problems which require accommodation?

Yes No

If yes, please specify

Educational Background:

For any uncompleted work, please list the expected degree and year of graduation.

Undergraduate

Institution

Degree

Major

Graduation Year

Graduate

Institution

Degree

Major

Graduation Year

Nurse Practitioner Program

Institution

Degree

Major

Graduation Year

Medical Interests:

What aspects of medicine do you find most interesting or appealing and why?

What aspects of medicine do you find least interesting or appealing and why?

What aspect of medicine is most disturbing to you?

What are your career interests?

Primary Care

Subspecialty

Other

Undecided

How interested are you in general pediatrics?

Very Much Somewhat Mainly interested in office/ambulatory experience

Preceptorship Information:

How many hours are needed?

How many patients do you need to see per day?

Please indicate your preferred placement dates and preferred days

Please upload a copy of your resume/CV. Your application will not be considered complete without your resume/CV.

Attach resume/CV

Add file

Please upload a file