Application - Learner


Viewing Current Application
Position Type:

Personal Information

First Name:	Last Name:	Gender:	M F N/A
Home Town:	Phone Number:	Use of Car:
Street:	Postal Code:
City:	Email:

School Information

Current University:

Student Number:
During this rotation, I will be in my year of School

Rotation Information

Rotation Dates:	From:	To:	Number of Weeks:
Rotation Type:			Preceptor, if known:
Rotation Discipline:

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.

Community Requests:
1st Choice: See Profile	Accomodations Required? No Yes	Connections to Community? No Yes
2nd Choice: See Profile	Accomodations Required? No Yes	Connections to Community? No Yes
3rd Choice: See Profile	Accomodations Required? No Yes	Connections to Community? No Yes
I Give Permission to select another community location if my choices are unavailable.