Forms and Policies:Undergraduates
ONTARIO STUDENTS: VISITING STUDENT ELECTIVES (YEARS 3 & 4)
   

Please fill out ALL the following fields and click on the SUBMIT button.
** Fields denoted by an asterisk(**) are definitely required.
First Name:**
Last Name: **
Address:
City:
Province:     
Postal Code:
Phone (home):   Phone (cell):   
E-mail Address:**
 
University:
Current Level of Training
   

Please use the following questions to let us know about the kind of elective you would like.
We will do our best to match you with a community that meets as many of your preferences as possible. If there is one details that is of greater importance to you than others (eg. only in January or really want OB) please let us know.
Which dates?
  First Choice:             TO   
  Second Choice:       TO   
  Third Choice:           TO   

 

Rank any or all of the following experiences in order of importance
  First:
  Second:
  Third:
  Fourth:
  Fifth:
  Sixth:
  Other:
   
What are your goals for this elective? (limit of 200 words)

Do you have a car?    
Yes    No  
Will you require accommodation?   
Yes   No  
   
Detail known preceptor information including whether you have a preference for a specific community or preceptor and whether a preceptor agreed to provide supervision for you during your elective.
How did you learn about the SWOMEN rural regional elective program?
Additional Comments