Medical Education

Medical Education Training Program

Externship Application for Elective Rotations


General Information
Full Name
Last
 First
 Middle Initial
Present Address:
City:
 State:
 Zip:
Email:
Home Phone:
 Cell Phone:
 Work Phone:
 
Education
College/University:
 City:
    State:
Degree:
 Graduation Date:
College/University:
 City:
    State:
Degree:
 Graduation Date:
Medical School:
 City:
    State:
Degree:
 Graduation Date:
Base Hospital (if applicable):
 
Rotations Requested
First Choice
Discipline:
 Dates:
Preferred Physician (if available):
Second Choice
Discipline:
 Dates:
Preferred Physician (if available):
 
Do you have health insurance?

 Do you need housing?

St. John Medical Center requires a letter of good standing, proof of malpractice and health insurance, and verification of current immunizations be sent directly from your school official. This information must be on file no later than four (4) weeks prior to the start of the rotation(s). We reserve the right to cancel your rotation if this information is not received.

I understand that St. John Medical Center and Ohio University College of Osteopathic Medicine assumes no liability for any medical costs incurred by me while I am participating in an elective at St. John Medical Center. I agree to notify St. John Medical Center at least 30 days in advance if I am unable to take this elective. I understand that confirmation of acceptance into any elective cannot be given until St. John Medical Center has notified me.
Your Signature: Date:

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