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Summer Observership 2013
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Summer Observership 2013
First and Last Name:
Nickname (if any):
Current Mailing Address :
Please list an address that you use currently
Permanent Mailing Address:
Please list your address AFTER August 1, 2013
Current Email:
Permanent Email:
Please list an email that you will check often after August 1.
PERSONAL INFORMATION
Date of Birth:
Month/day/year
Number in your party?:
I am coming alone
I am bringing my spouse/partner
I am bringing my spouse/partner & children
I am bringing my children
Note: Placement may be limited due to housing needs.
Marital Status:
Married
Single
Spouse/Partner Name (If applicable):
Names, gender & ages of children (if applicable):
Religious Affliliation (if any):
--Select--
No affiliation
Spiritual
not religious
Christian
LDS
Baptist
Mennonite
Jewish
Catholic
Episcopal
Evangelical Christian
7th Day Adventist
Jewish-Orhodox
Methodist
Protestant
Lutheran
Muslim
Buddhist
Other
Interests & Activities:
basketball
birdwatching
bowling
camping
chess
computers
cooking/fine cuisine
cycling/mountain biking
farming/ranching
fishing
football
gardening/horticulture
golf
hiking/backpacking
history
horseback riding
hunting
literature
magic
movies/film
music
playing instruments(s)
photography
rafting/canoeing
rock climbing
rock hunting/geology
running
sailing
science fiction
scuba diving
sewing/quilting/needlework
skiing
sports
surfing
swimming
tennis
theater/acting
visual arts
volleyball
waterskiing
wine tasting
wine or beer making
woodworking
working out/gym/classes
writing
other
TRANSPORTATION & HOUSING
Transporation arrangements:
I have my own transportation
I am willing to drive student(s) to sites near mine
I can drive myself but not others
I would prefer getting a ride with other student(s)
I am willing to arrange to take the bus/train to site
Please select one option
Allergies:
Dogs-CAN'T be in home with dogs
Cats-CAN'T be in home with cats
No allergies that affect housing
Other
If you checked "Other Allergies" above, please list:
Dietary Preferences:
Vegetarian
Vegan
No Dietary Preferences
Food Allergies
Other
If you checked Other, please list:
PRECEPTORSHIP INFORMATION
Preceptor Gender Preference:
No Preference
Male (if possible)
Female (if possible)
Indicate your preferred level of involvement:
To be involved in all physician and familiy activities in which they feel comfortable including me
to have more personal space and/or "alone time"
Specialty Interest in Medicine:
Please list in order of priority
I would like to be placed in a Spanish-speaking site:
Yes
No
Please describe your Spanish fluency:
--Select--
I speak a little Spanish
I speak a moderate amount Spanish
I am fluent in Spanish
but not medical Spanish
I am fluent in medical Spanish
If available, I would like placement in a migrant or Native American health care site:
Yes
No
If you answered yes, why would you like to be placed in either of these sites?:
EDUCATION/EXPERIENCE
College:
College Major:
Relevant Community/Volunteer Experience:
Relevant Work Experience:
