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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.
career/specialty
Note: This is not a reason to keep you in the N.O. metro area
Note: if you are a military scholar student and wish to do this rotation at a pre-approved military site, it is imperative that you let us know.
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.