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AHS Medical Student
Externship Application

Application must be submitted no later than March 24, 2008 to be considered. Decision date is April 1, 2008.

Contact Information

First Name*Phone Number*
Last Name*E-mail*

Address Information
School/Temporary Address

Home/Permanent Address
StreetStreet
CityCity
StateState
ZipZip
PhonePhone

Externship Location & Dates
Externship Location Preference*
Preferred Dates for Externship*

Letter for Application (Fields expand to accomodate full response)
What do you hope to gain from this experience?
What healthcare/hospital experience have you had?
What are some of your outside interests?
List further qualifications for selection:

Other Information
Medical School
Undergraduate School

Note: If checked, proof of valid license and insurance is required
Emergency Contact Person and Number

Learning Electives/Preferences

Please indicate all elective learning experiences that you would be interested in observing / participating in and rank your top five (1 = first preference). While your experience will be designed with these preferences in mind, actual experience will depend on staffing and scheduling availability.
                        Interest/Activity

Rank

Submission of this application will notify AHS of your desire to participate in the Medical Externship and will automatically request a letter of reference from the office of the Associate Dean for Student Affairs, LLU School of Medicine. Applicants from other Medical Schools must contact the AHS Director of Leadership Development for further instructions.

NOTE: If you do not see a confirmation page after clicking Submit, scroll up to check incorrect data that has been flagged.

 
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