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State / Province / Region
Postal / Zip Code
Emergency Contact Phone:
Current year in school:
Have you Passed Step 1/COMLEX Level 1 With No More Than One Examination Failure?
Preferred rotation date:
08/23/21 - 09/17/21
09/20/21 - 10/15/21
10/18/21 - 11/12/21
11/15/21 - 12/10/21
01/03/22 - 01/28/22
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:
7 + 14 =