Emergency Medicine Medical Student Clerkship Application (EM Sub-I and EM Selective rotations)

Personal Info

First Name Last Name Email Address Phone Number Street Address 1 Street Address 2 City State Zip Code Medical School MS3 MS4 Are you planning to apply for Emergency Medicine Residency? Yes No Rotation Requested

Requested Rotation date(s) to start a 4 week block

1st Choice 2nd Choice 3rd Choice

Miscellaneous

In ONE paragraph explain why you are interested in Emergency Medicine: In ONE paragraph, explain why you are interested in rotating at UPMC in Central Pa:

I understand that by providing my email address, I agree to receive emails from UPMC. I understand that I may opt out of receiving such communications at any time.

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Contact UPMC in Central Pa.