Pediatric Preceptorship Student Application

Summer Break Preceptorship Applications are due March 31, 2019. Spring break applications are due on February 1, 2019. 

Personal Information
Contact information
In case of emergency
Educational Background

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

Undergraduate
Graduate
Medical
Medical Interests
Preceptorship Information

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

This will not effect your acceptance into this program.

Please indicate your preferred city or town and the number of miles you are willing to commute.

Please note that TPS cannot guarantee a match with a requested preceptor.
Learning Style (please limit responses to a few brief sentences)
I hereby give the Texas Pediatric Society, the Texas Chapter of the Academy of Pediatrics, its successors and assigns those acting under its permission or upon its authority, the unqualified right and permission to reproduce, copyright, publish, circulate, or otherwise use my name/or photographic likeness of me still, single, multiple or moving in which I may be included in whole or in part, or composite. I waive any right to inspect or approve the finished product, products, or copy that may be used or the use to which it may be applied. This authorization and release covers the use of said materials in any published or broadcast form, and any medium of advertising, publicity, or trade in any part of the world for any unlimited period of time. Furthermore, for the consideration above mentioned, I, myself, heirs, executors, administrators, or assigns, transfer to the organization, its successors and assigns, all of my rights, title, and interests in and to all reproductions taken of me by representatives or the organization. This agreement represents in full all terms and considerations and no other inducements, statements, or promises have been made to me.
Please upload a photo or scan of your student ID.
Files must be less than 2 MB.
Allowed file types: gif jpg png pdf.
Acknowledgement of Understanding

For additional information, please contact:
Anslee Boozer, Pediatric Program Coordinator

401 West 15th Street, Suite 682
Austin, Texas 78701
(512) 370-1563 fax: (512) 473-8659