*All fields are Required
First Name:
Last Name
E-mail:
Phone Number
Street Address:
City
State / Province / Region
Postal / Zip Code
Emergency Contact:
Contact Name
Emergency Contact Phone:
Medical School:
Current year in school:
Have you passed Step 1 with no more than one examination failure?
yes
no
Preferred Sub-internship date:
First Choice:
07/27/20 - 08/21/20
08/24/20 - 09/18/20
09/21/20- 10/16/20
10/19/20 - 11/13/20
11/16/20 - 12/11/20
01/04/21 - 01/29/21
Second Choice:
Tell us about your interest in family medicine:
List the learning objectives for your sub-internship in your own words (Do not list your school's objectives)
Do you have family or other ties to the Ellensburg area?
Do you need a place to stay?
Are you applying for residency here?
Are you a U.S. Citizen or Permanent Resident?
To prove you are human - Please solve this equation.
Enter the answer in the box: 8 + 3 =
