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First Name:
Last
E-mail:
Phone:
Street Address
City
State / Province / Region
Postal / Zip Code
Emergency Contact:
Name
Emergency Contact Phone:
Medical School:
Current year in school:
Have you Passed Step 1/COMLEX Level 1 With No More Than One Examination Failure?
yes
no
Preferred rotation date:
First Choice:
08/22/22 - 09/16/22
09/26/22 - 10/21/22
10/24/22 - 11/18/22
11/21/22 - 12/16/22
01/02/23 - 01/27/23
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 Yakima area?
Do you need a place to stay?
Are you applying for residency here?
Are you interested in the Ellensburg Rural Program? ?
Our Ellensburg Rural Program is not offering full rotations, however, we can build some time into your Yakima schedule to visit Ellensburg for specific program activities.
Are you a U.S. Citizen or Permanent Resident?
Have you received a COVID-19 vaccination?
To prove you are human - Please solve this equation.
Enter the answer in the box:8 + 3 =
