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Family & Community Medicine ~ Clerkship ~ Student Profile Form

Ex. 504-555-6789
Ex. 504-555-1234
Ex. January 3 - February 11
Include City and State
Include other background that would be helpful
If so, please list.
Note: This is not a reason to keep you in the N.O. metro area
If No, you must arrange transportation by the time of the rotation. By request, we will attempt to pair you at a site with a student who does.