BEFORE YOU ARRIVE TO START YOUR ROTATION, SEND THIS COMPLETED FORM (SENT BY E-MAIL BEFORE YOUR CLERKSHIP) TO YOUR CLERKSHIP SITE COORDINATOR VIA E-MAIL OR US MAIL

NAME: __________________________________ CLERKSHIP SITE: ___________________
ADDRESS: _______________________________ CLERKSHIP DATES: __________________
_________________________________________ YEAR IN SCHOOL: 3 4 _________________________________________

PHONE: ___________________________

First Yr. Spent at (please circle one):
UW    WSU    UWY    UA    UI    MSU

PAGER: ___________________________

    For Madigan students only:
        Social Security Number: _________________________

        Birth Date: __________________________

EDUCATION:

    College(s) ______________________________________

    Major(s) ____________________ Degree(s) _______________________

MAJOR CLERKSHIPS COMPLETED: _________________________________________________

AMBULATORY CARE EXPERIENCES: (include clerkship or course name and number of weeks/hours spent in ambulatory care) _______________________________________ _____________________________________________________________________________

HOUSING NEEDS: According to our records, you have indicated the following housing needs:

Housing for yourself only:        YES _________ NO _____________

Spouse will accompany me:        NO __________ YES __________ Dates:____________________

WWAMI will NOT pay for an unmarried partner's travel and accommodations. UW will pay for visits that are no less than 2 weeks in duration.

Spouse and Children will accompany me:        NO __________ YES _________ Dates:____________________ Number of children accompanying __________

Willing to share housing with another medical student of the opposite sex:        YES _________ NO ____________

We want to get to know you as a person. Please provide your Site Coordinator with the following information (none of this data will in anyway be reflected in the faculty's evaluation of you).

PRIOR JOBS OR PURSUITS: ___________________________________________________

TRAVELS: __________________________________________________________________

HOBBIES/INTERESTS: ________________________________________________________

BIRTHPLACE: ________________ WHERE WERE YOU RAISED? _____________________

OTHER PLACES THAT YOU HAVE LIVED: _________________________________________

SHORT AND LONG TERM CAREER PLANS: _________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

FUTURE GOALS (OUTSIDE OF MEDICINE): _______________________________________ ____________________________________________________________________________ ____________________________________________________________________________

YOUR EXPECTATIONS FROM THIS ROTATION: _____________________________________ ____________________________________________________________________________ ____________________________________________________________________________