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Externship Application - Kettering Medical Education

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Focus on Curriculum Internal Medicine

Focus on Curriculum Transitional Year

The application period for the Summer Externship Program begins Jan 1, 2008.

Name:

Phone (including area code):

Email Address:

Medical school you are currently attending:

School Address:

Street:

City:

State

Zip:

Email:

Hometown Address:

Street:

City:

State:

Zip:

Important: Where we can reach you in the summer?

Please provide phone #, and/or email:

Undergraduate institution you attended:

I will require room accommodations for externship:

Yes No

I will need a car during the externship:

Yes No

Emergency contact person and phone number:

NOTE: Students will need a valid driver's license and insurance coverage to use the Med Ed loaner car. Students will need to drive themselves to off-campus specialty locations.

Please select three time frames from the list below:
You must be available for any of the dates you choose, even if they are not your first choice.

June 9 - June 20

First Choice Second Choice Third Choice

June 16 - June 27

First Choice Second Choice Third Choice

June 23 - July 4

First Choice Second Choice Third Choice

June 30 - July 11

First Choice Second Choice Third Choice

July 7 - July 18

First Choice Second Choice Third Choice

Jul 14 - Jul 25

First Choice Second Choice Third Choice

July 21- August 1

First Choice Second Choice Third Choice

July 28 - August 8

First Choice Second Choice Third Choice

August 4 - August 15

First Choice Second Choice Third Choice

August 11 - August 22

First Choice Second Choice Third Choice

August 18 - August 29

First Choice Second Choice Third Choice

August 25 - September 5

First Choice Second Choice Third Choice

Application must be submitted no later than March 1, 2008 to be considered.
Decision date is March 7, 2008.
(SS# will be required when you are accepted, to validate your stipend payment)

Subspecialties and Additional Opportunities for Learning
Choose five preferences, with 1 being the most favored and 5 being the least.

Subspecialties
(Choose and rank 5 subspecialties - Other rotations may be considered upon request)

Cardiology/Cath Lab

0

1

2

3

4

5

Gastroenterology-Endoscopy

0

1

2

3

4

5

EKG/ECHO

0

1

2

3

4

5

Neurology

0

1

2

3

4

5

HIV Clinic/Infectious Diseases

0

1

2

3

4

5

Pulmonary/ICU (HB)

0

1

2

3

4

5

Ophthalmology

0

1

2

3

4

5

Additional Opportunities
(Choose and rank 5 additional opportunities - Other rotations may be considered upon request)

Emergency Medicine

0 1

2

3

4

5

Pathology/Laboratory

0

1

2

3

4

5

Nuclear Medicine

0

1

2

3

4

5

Surgery Observation

0

1

2

3

4

5

Good Neighbor House (indigent clinic)

0

1

2

3

4

5

Sycamore Primary Care

0

1

2

3

4

5

Sports Medicine

0

1

2

3

4

5

Other areas of interest not listed:

Letter of Application

What do you hope to gain from this experience?

What healthcare/hospital experience have you had?

What are some of your outside interests and extra-curricular activities?

Further qualifications, reasons for application, or experience:

Contact: Kate Hawvermale, Student Coordinator(937)298-3399 x55599 Click here to send email.

Contact us at:
Department of Medical Education, Kettering Medical Center
3535 Southern Blvd, Kettering, OH 45429
Phone: (800)203-8925