Application - Learner
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Position Type:
 


Personal Information
First Name:   Last Name:   Gender: M F
Home Town:   Phone Number: Use of Car:
Street: Postal Code:
City:   Email (use as login):  
School Information
Current University:
Date of MD:
Student Number:    
During this rotation, I will be in my year of medical School Clerk
Rotation Information
Rotation Dates: From:   To:   Number of Weeks:
Rotation Type: Preceptor, if known:
Rotation Discipline:
Community Requests:
1st Choice:  
See Profile  
Accomodations Required?
Connections to Community?
2nd Choice:  
See Profile
Accomodations Required?
Connections to Community?
3rd Choice:  
See Profile
Accomodations Required?
Connections to Community?
   
Expectations of Learning Experience
Please clearly indicate any educational expectations (clinic, hospital or other) to ensure that you are matched with a preceptor who meets your learning objectives. Please also note any additional details regarding community placement, or accommodation requests in the notes section below.

Program Coordinator Notes:
Please add your program co-ordinator information and pertinent contact details.

Name of Program Director:

  By submitting this application, I agree to abide by all of the policies (available at http://romponline.com/wp-content/uploads/2014/09/ROMP-PreceptorLearnerPolicyManual2011.pdf) and confirm that I have not applied to any other rural placement programs. I understand that once the ROMP coordinator has contacted me with the name of a preceptor, it is unprofessional for me to cancel the rotation. I acknowledge that ROMP will notify my school of any unprofessional behaviour.