Application - Learner
Viewing Current Application
Position Type:
Dietician/Nutritionist
Medical Student/Clerk
Medical Resident
Midwife
Nurse Practitioner
Observer
Physical Therapy
Physician Assistant
Psychologist
Personal Information
First Name:
Last Name:
Gender:
M
F
N/A
Home Town:
Phone Number:
Use of Car:
Yes
No
Street:
Postal Code:
City:
Email:
School Information
Current University:
McMaster University
Northern Ontario School of Medicine
Other
Out of Country
Out of Province
Queen's University
University of Ottawa
University of Toronto
University of Western Ontario
Student Number:
During this rotation, I will be in my
1
2
3
4
5
6
7
8
year of School
Rotation Information
Rotation Dates:
From:
To:
Number of Weeks:
Rotation Type:
Core
Elective
Rural Medicine Week
Summer Elective
Summer Student
Preceptor, if known:
Rotation Discipline:
Anaesthesiology
Cardiac Surgery
Cardiology
Clinical Immunology and Allergy
Colorectal Surgery
Critical Care (CCU) Medicine
Critical Care (ICU) Medicine
Dermatology
Diagnostic Radiology
Emergency Medicine
Endocrinology and Metabolism
Family Medicine
Family Medicine (Anes)
Family Medicine (EM)
Gastro-Enterology
General Surgery
General Surgery Oncology
Geriatric Medicine
Hematology
Hospitalist (FM)
Hospitalist (IM)
Infectious Disease
Internal Medicine (General)
Medical Genetics
Medical Oncology
Nephrology
Neurology
Nuclear Medicine
Obstetrics and Gynecology
Ophthalmology
Orthopaedic Surgery
Other
Otolaryngology
Paediatrics
Palliative Medicine
Pathology
Physical Medicine and Rehabilitation
Plastic Surgery
Psychiatry
Public Health and Preventive Medicine
Radiation Oncology
Respirology
Rheumatology
Sports Medicine
Thoracic Surgery
Urology
Vascular Surgery
Community Requests:
1
st
Choice:
Barrie
Brant County (Ayr, Brantford, Paris, St George, Waterford)
Cambridge
Centre Wellington (Elora, Fergus)
City of Kawartha Lakes (Bobcaygeon, Fenelon Falls, Lindsay, Woodville)
Clarington Township (Bowmanville, Newcastle)
Collingwood-Creemore-Stayner-Wasaga Beach
Erin
Exeter
Fort Erie
Georgina-Keswick-Sutton
Guelph
Haldimand County (Caledonia, Cayuga, Dunnville, Hagarsville, Haldimand)
Haliburton
Halton Hills (Georgetown, Limehouse)
Hanover
Innisfil
Kincardine
Kinmount-Minden
Lions Head
Listowel
Markdale
Markham-Stouffville
Meaford
Midland-Penetanguishene
Milton
Minden
Minto-Mapleton (Drayton, Palmerston)
New Tecumseth (Alliston, Beeton, Tottenham)
Niagara Falls
Niagara on the Lake
Norfolk County (Delhi, Jarvis, Port Dover, Simcoe)
Northumberland (Cobourg, Port Hope)
Norwich
Orangeville (Shelburne)
Orillia
Owen Sound
Peterborough
Port Colborne
Port Elgin
Port Perry
Rousseau/Wahta
Seaforth
South Hampton
Thorold
Tillsonburg
Town of the Blue Mountains (Clarksburg, Thornbury)
Trent Hills (Campbellford, Hastings, Warkworth)
Uxbridge
Walkerton
Welland
Wellington North (Arthur, Mount Forest)
West Lincoln (Beamsville, Grimsby, Smithville)
Wiarton
Wingham
See Profile
Accomodations Required?
No
Yes
Connections to Community?
No
Yes
2
nd
Choice:
Barrie
Brant County (Ayr, Brantford, Paris, St George, Waterford)
Cambridge
Centre Wellington (Elora, Fergus)
City of Kawartha Lakes (Bobcaygeon, Fenelon Falls, Lindsay, Woodville)
Clarington Township (Bowmanville, Newcastle)
Collingwood-Creemore-Stayner-Wasaga Beach
Erin
Exeter
Fort Erie
Georgina-Keswick-Sutton
Guelph
Haldimand County (Caledonia, Cayuga, Dunnville, Hagarsville, Haldimand)
Haliburton
Halton Hills (Georgetown, Limehouse)
Hanover
Innisfil
Kincardine
Kinmount-Minden
Lions Head
Listowel
Markdale
Markham-Stouffville
Meaford
Midland-Penetanguishene
Milton
Minden
Minto-Mapleton (Drayton, Palmerston)
New Tecumseth (Alliston, Beeton, Tottenham)
Niagara Falls
Niagara on the Lake
Norfolk County (Delhi, Jarvis, Port Dover, Simcoe)
Northumberland (Cobourg, Port Hope)
Norwich
Orangeville (Shelburne)
Orillia
Owen Sound
Peterborough
Port Colborne
Port Elgin
Port Perry
Rousseau/Wahta
Seaforth
South Hampton
Thorold
Tillsonburg
Town of the Blue Mountains (Clarksburg, Thornbury)
Trent Hills (Campbellford, Hastings, Warkworth)
Uxbridge
Walkerton
Welland
Wellington North (Arthur, Mount Forest)
West Lincoln (Beamsville, Grimsby, Smithville)
Wiarton
Wingham
See Profile
Accomodations Required?
No
Yes
Connections to Community?
No
Yes
3
rd
Choice:
Barrie
Brant County (Ayr, Brantford, Paris, St George, Waterford)
Cambridge
Centre Wellington (Elora, Fergus)
City of Kawartha Lakes (Bobcaygeon, Fenelon Falls, Lindsay, Woodville)
Clarington Township (Bowmanville, Newcastle)
Collingwood-Creemore-Stayner-Wasaga Beach
Erin
Exeter
Fort Erie
Georgina-Keswick-Sutton
Guelph
Haldimand County (Caledonia, Cayuga, Dunnville, Hagarsville, Haldimand)
Haliburton
Halton Hills (Georgetown, Limehouse)
Hanover
Innisfil
Kincardine
Kinmount-Minden
Lions Head
Listowel
Markdale
Markham-Stouffville
Meaford
Midland-Penetanguishene
Milton
Minden
Minto-Mapleton (Drayton, Palmerston)
New Tecumseth (Alliston, Beeton, Tottenham)
Niagara Falls
Niagara on the Lake
Norfolk County (Delhi, Jarvis, Port Dover, Simcoe)
Northumberland (Cobourg, Port Hope)
Norwich
Orangeville (Shelburne)
Orillia
Owen Sound
Peterborough
Port Colborne
Port Elgin
Port Perry
Rousseau/Wahta
Seaforth
South Hampton
Thorold
Tillsonburg
Town of the Blue Mountains (Clarksburg, Thornbury)
Trent Hills (Campbellford, Hastings, Warkworth)
Uxbridge
Walkerton
Welland
Wellington North (Arthur, Mount Forest)
West Lincoln (Beamsville, Grimsby, Smithville)
Wiarton
Wingham
See Profile
Accomodations Required?
No
Yes
Connections to Community?
No
Yes
I Give Permission to select another community location if my choices are unavailable.
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.