Contact Information Last Name First Name	Phone Number Email
Address Information School/Temporary Address     Street City State Zip Code Phone	Home/Permanent Address Street City State Zip Code Phone
Externship Location & Dates
Externship Location Preference	Florida Hospital - Orlando, FL Adventist Hinsdale Hospital - Hinsdale, IL Shawnee Mission Medical Center - Shawnee Mission, KS
Preferred Dates for Externship	June 25 - July 13, 2007 July 9 - July 27, 2007 July 16 - August 3, 2007 July 23 - August 10, 2007 July 30 - August 17, 2007 August 6 - August 24, 2007
Letter for Application  (Fields expand to accomodate full response)
What do you hope to gain from this experience?
What healthcare/hospital experience have you had?
What are some of your outside interests?
List further Qualification for selection
Other Information
Medical School Undergraduate School	Check box if you will require housing be provided. Check box if you will require a car to be provided. Note:If checked, proof of valid license and insurance is required
Emergency Contact Person and Number
Learning Electives/Preferences Please indicate all elective learning experiences that you would be interested in observing / participating in and rank your top five (1 = first preference).While your experience will be designed with these preference in mind,actual experience will be depend on staffing and scheduling availablity.
Interest Rank Activity N/A 1 2 3 4 5 Risk Management (case review) N/A 1 2 3 4 5 Surgery (DaVinci, robotic, etc.) N/A 1 2 3 4 5 Evidence-based Medicine Online Conference and Project N/A 1 2 3 4 5 Medical Staff Meetings N/A 1 2 3 4 5 Managing Physician Training N/A 1 2 3 4 5 CPR and/or ACLS N/A 1 2 3 4 5 Computerized Patient N/A 1 2 3 4 5 Hospitalist Rounds N/A 1 2 3 4 5 Physician Leadership N/A 1 2 3 4 5 Medical Mission (Shepherd�s Hope Clinic) N/A 1 2 3 4 5 Physician Office Infomatics (electronic medical records, PAC, etc.) N/A 1 2 3 4 5 Intensivist Rounds N/A 1 2 3 4 5 Urgent Care N/A 1 2 3 4 5 Occupational Medicine N/A 1 2 3 4 5 Sports Medicine / Rehab