UNIVERSITY OF LOUISVILLE SCHOOL OF DENTISTRY
VISITING STUDENT APPLICATION
The University of Louisville School of Dentistry (ULSD) welcomes requests for clinical rotation experiences from students enrolled in an ADA-accredited American dental school. Students requesting visiting student status must complete the application process.
Students requesting Visiting Student Status must adhere to the following guidelines:
· Must have completed at least the first semester of the third year of dental school.
· Must have approval of the dental school in which student is currently enrolled.
· Must provide evidence of meeting all immunization requirements.
· Must provide proof of medical health insurance to cover expenses which may arise as the result of illness or injury occasioned during the period of clinical rotation.*
· Must provide proof of medical malpractice insurance coverage.
· Must sign ULSD’s Confidentiality Statement and provide proof of training in the confidentiality of protected health information (HIPAA).
There are no salaries, housing, meals, name badges, uniforms or ID cards provided by the University of Louisville School of Dentistry to Visiting Students. Tuition will not be charged. If you have a name badge and/or picture ID by your school, please bring it with you. You may be asked to show a form of identification when you report for your rotation.
Please complete Section I of the Visiting Student Application and have your dental school complete Section II. You will be notified by mail (or email) when your application has been processed.
We reserve the right to terminate a student’s rotation at ULSD if he/she does not comply with the School’s policies and procedures or for misconduct.
*Visiting students are not employees of the School and therefore are not protected by Worker’s Compensation. ULSD does not assume any liability for injuries or illness in the absence of a showing of actual negligence on the part of the School.
UNIVERSITY OF LOUISVILLE SCHOOL OF DENTISTRY
VISITING STUDENT APPLICATION
Complete form and return to:
Lana Stokes
Surgical & Hospital Dentistry
School of Dentistry, Room 148
University of Louisville
Louisville, KY 40292
REQUESTS MUST BE RECEIVED AT LEAST 2 MONTHS PRIOR TO BEGINNING REQUESTED ROTATION
SECTION I: (To be completed by student)Name:
Address:
Soc. Security No.: / Date of Birth: / □ Male □ Female
E-Mail Address: / Phone(s):
Dental School Name & Address that you are currently enrolled:
I HEREBY VERIFY THAT THE ABOVE INFORMATION IS CORRECT
AND THAT I WILL HAVE HEALTH INSURANCE COVERAGE AND
MALPRACTICE INSURANCE COVERAGE AT ALL TIMES DURING MY VISIT.
Signature: Date:
Clinical experience desired: OMFS Externship
Request for the following dates (subject to approval by ULSD) :
SECTION II – (To be completed by school official at student’s dental school.)
□ Yes □ No / Will this course count towards the student’s graduation requirements?
□ Yes □ No / Will an evaluation form be required at the end of the program?
□ Yes □ No / Will tuition be paid at your school during the period away? SCHOOL SEAL
□ Yes □ No / Is the student covered by malpractice insurance?
Please indicate the student’s class rank:
□ Upper □ Middle □ Lower
Name of Official (print):
Title:
Signature of Official: / Date:
SECTION III – To be completed by Department at ULSD
Your application for the clinical program has been: Approved: □ Yes □ No
Course #: OMFS Externship for the following dates:
Department Signature: Date:
Phone Number: 502-852-3534
Departmental Contact Person*: Lana Stokes Phone: 502-852-3534
*Once a student has been granted Visiting Student Status, all future correspondence will be via the Dept. Contact Person.
SECTION IV – (To be completed by the Office of Graduate Education at ULSD
A copy of this form will be sent to the Department after it has been approved by the Associate Dean for Graduate Education. The original application will kept on file in the Office of Graduate Education. Approved: □ Yes □ No Associate Dean’s Signature: Date:
I: visitingstudentapplication (2/12/17)