DIRECTIONS 

1: This form is only for the application for an away clinical elective (defined as an elective listed in the host school's/institution's course catalog). 

2: You may only complete this form after the host school/institution has accepted you for the elective.

3: In order to submit this form, you must attach PDF copies of the catalog description of the elective, as well as your proof of acceptance from the host school/institution. 

4: After your elective ends: It is your responsibility to make sure that your elective is graded. Complete the student portion of the Elective Grade/Evaluation Form at the end of your rotation which will be automatically emailed to the evaluator email you submit. 


Student Information

STUDENT NAME*
What is your projected graduation year


DETAILS OF ELECTIVE AT OTHER SCHOOL/INSTITUTION 

Select from the dropdown
100 character limit
100 character limit
ELECTIVE START DATE*
ELECTIVE END DATE*
List in numerical value the amount of hours per week you will be spending on this elective
List in numerical value the total number of weeks you will be spending on this elective
NAME OF PRECEPTOR/INSTRUCTOR*
Optional
Optional


REQUIRED DOCUMENTS

Upload a PDF copy of the official course description of the elective *
No File Chosen
File uploads may not work on some mobile devices.
This must be from the school/institution's course catalogue
Upload a PDF copy of your official proof of acceptance from the host school/institution*
No File Chosen
File uploads may not work on some mobile devices.


ATTESTATIONS

CONFLICT OF INTEREST: I attest that I will not be under the direct supervision of any family members or individuals with whom I have a personal relationship*
ELECTIVE REQUIREMENTS*
Use your mouse or finger to draw your signature above
TODAY'S DATE / TIME *
Signed by student

Director of Medical Student Electives

DIRECTOR OF MEDICAL STUDENT ELECTIVES*
Review Date*
Signed by Director of Medical Student Electives
From Director of Medical Student Electives

Office of Registrar

OFFICE OF THE REGISTRAR*
Review date*
From Office of the Registrar
Do the start or end date need to be revised?*
Final Elective Start Date*
Final Elective End Date*