Med Student Application Form

Personal Information

Name Address Apt City State Zip Email Cell-Phone Number Emergency Contact Will You Require a Visa Sponsor? Yes No

Medical School Information

Medical School Anticipated Medical School Graduation Date

Medical School Registrar Contact Information:

Registrar Contact Name School Phone Number School Contact Email

Application

Select your rotation type Sub-I Elective

Requested Rotation date(s) to start a four-week block. To enter a date range, please use this format: "July 9th - Aug 5th, 2023". Slashes are not allowed.

1st Choice 2nd Choice 3rd Choice

Board Exam / AOA / SSP

USMLE Step 1 USMLE Step 2 CK USMLE Step 3 CS COMLEX Step 1 COMLEX Step 2

Alpha Omega Alpha/Sigma Sigma Phi Member Details Was your medical education / training extended or interrupted? Yes No Were you part of a military GMO after graduating? Yes No Were you involved in Emergency Medicine interest group(s)? In one paragraph, explain why you are interested in Emergency Medicine In one paragraph, explain why you are interested in rotating at Riverside Regional Medical Center Do you need housing? Yes No I understand that housing provided by Riverside is a coed environment for medical students interested in EM, IM, FM and OB/GYN. Each bedroom is set up for double occupancy of the same gender. Housing in the Riverside apartment may be revoked at any time.