4th Year Elective Application

Thank you for your interest in an elective rotation with Maine-Dartmouth. Complete the form below to apply online and a member of our team will be in touch with you.

Application for Medical Student Elective Rotation at MDFMR

Because of great interest in the MDFMR Medical Student Elective Program, we require a completed application and all supporting documents including a copy of your immunization records, transcript, Step One scores, current background check (within a year of your requested rotation) with no adverse findings, and a letter from your school stating you are a current student in good standing and will be covered by malpractice insurance during your rotation (with a copy of the certificate). Please mail, e-mail, or fax these documents to the medical student coordinator once you submit this online application. Only completed applications will be considered. Thank you for your interest in our program!

PERSONAL INFORMATION

Name
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Mailing Address
Emergency Contact Name

EDUCATION INFORMATION

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Please tell us how many weeks of the following core clerkships you will have successfully completed prior to beginning the elective rotation you are requesting.
Please enter a number from 0 to 100.

APPLICATION QUESTIONS

Are you planning to interview with the FM Residency if invited to do so during recruitment season?
Do you plan to stay in the housing provided for students at the cost of $50.00/week? Please note that our housing can only accommodate the rotating student -- family & pets are not allowed.
Please select the rotation you are interested in.

Please tell us what your first date choice is:
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Please tell us what your second date choice is:
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Please tell us what your third date choice is:
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ADDITIONAL APPLICATION QUESTIONS: Please complete if you are applying for an OSTEOPATHIC MANIPULATIVE MEDICINE rotation.

ADDITIONAL APPLICATION QUESTIONS: Please complete if you are applying for an OUTPATIENT INTEGRATIVE MEDICINE elective.

How much exposure to integrative medicine have you had thus far?
Have you had hands-on experience with integrative medicine in a clinical setting with a real patient?
What specific topics within integrative medicine interest you the most? Select all that apply.

Please note: Vehicle transportation is required given our rural location.