Family & Community Medicine ~ Clerkship ~ Student Profile Form

Last Name

First Name

Middle Initial

Age

Box

Phone #

Emergency Contact Name and Phone #

Block Date

Undergraduate School

Degree

Major

Graduate School

Graduate Degree

Graduate Major

Where did you grow up or call home? Describe the community where you grew up.

Include City and State

What are some of your prior career/life experiences?

Why are you going into medicine/what drew you to medical school?

What are your current/special interests in medicine?

What are some of your special interests outside of medicine?

Tell us about your family.

Include other background that would be helpful

Are you fluent in any languages other than English?

If so, please list.

Describe any current student organization/leadership activities.

Note: This is not a reason to keep you in the N.O. metro area

Are you in the Military?

If yes, which branch?

Are you enrolled in a Tulane MPH program?

Do you have a means of transportation?

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.

Do have a roommate on this block?

If so, who?

If being placed out of town, is there someone(s) with whom you would like to live.

Are you off-cycle in your third year? If so, which block will this really be for you?

Describe any special placement requests or considerations. (If you have something confidential to discuss, please contact us separately from this form.)

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Family & Community Medicine ~ Clerkship ~ Student Profile Form