Application - Summer Student / Hire a Med Student
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:
Do you have connections to a rural community?  If so please select the closest one you would prefer to work in:
Accomodations Required?
Connections to Community?
Letter of Intent
Please clearly indicate why you are interested in this program. Outline any relevant past experiences and your reasoning for wanting to get involved in rural medicine. Please note any additional details regarding you community placement or accommodation requests.

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 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.