Student Profile

The deadline for preclinical applicants was March 3rd. Currently, we are only accepting applications from 3rd and 4th year students.

Personal Information

First Name: *

Last Name: *

Nickname:

DOB: *

Gender:

Male

Female

Married:

Yes

Do you speak Spanish?: *

Yes

Do you speak any other languages?:

Ethnicity: (optional)

Religion: (optional)

Where did you grow up? :

Rural

Urban

Other

Please list your hobbies and extracurricular activities below.:

Contact information

Street:

City:

State:

Zip:

Phone: *

Mobile:

Email: *

In case of emergency

Contact:

Phone:

Mobile:

Do you have any physical limitations or medical problems which require accomodation? :

Yes

If yes, please specify:

Educational Background

For any uncompleted work, please list the expected degree and year of graduation.

Undergraduate

Institution:

Degree:

Major:

Graduation Year:

Graduate

Institution:

Degree:

Major:

Graduation Year:

Medical

Institution: *

Degree:

Major:

Graduation Year: *

Year of medical school: *

First

Second

Third

Fourth

Preceptorship Information

Please indicate your preferred placement dates (pick four consecutive weeks)

First choice start date: *

First choice end date: *

Second choice start date:

Second choice end date:

Please indicate your preferred city or town.

First choice: *

Second choice:

Third choice:

Geographical preference:

Urban

Rural

Inner city

Any

Would you like to request a specific preceptor?:

Yes

Preceptor:

Past medical and/or relevant work experience (including courses completed):

What factors might limit your participation (housing, family, etc)?:

Learning Style

How do you learn best?:

What stifles or hinders your learning?:

Describe the qualities of an effective teacher.:

Acknowledgement of Understanding

Acknowledgement #1: *

I understand that I must fax scan/email or mail a copy of my student ID with photo to be included with this profile to Amy White (see contact information below) before the profile will be considered complete.

Acknowledgement #2: *

I affirm that all information above is complete and correct to the best of my knowledge. I understand that this information will be used in confidence by the Program Coordinator at the medical school and the physician preceptor.

Acknowledgement #3: *

I understand that this rotation is unpaid and that I will not be compensated with a stipend.

For additional information, please contact:
Amy White, Program Director

401 West 15th Street, Suite 682
Austin, Texas 78701
(512) 370-1519 fax: (512) 473-8659