Application for Funded Clinical Rotation for
Students from Underrepresented Backgrounds
Section 1: Student Data
Name: ______Gender (circle): F M
Last, First, M.I.
Address: ______
Street/City/State/ZIP code
Phone: ( _ _ _ ) _ _ _ - _ _ _ _ Email: ______DOB: ______
Race/Ethnicity (please circle):
African American
Mexican American
Mainland Puerto Rican
Native American (American Indians, Native Hawaiians, Alaskan Natives)
Other ______
Section 2: Rotation Date Requests
The funded rotation will be available from August 2015 through December 2015. Start and end dates include the following:
Summer C: 8/31-9/25/15
Autumn A: 9/28-10/23/15
Autumn B: 10/26-11/20/15
Autumn C: 11/23-12/18/15
Please rank your rotation preferences from 1 to 4, with 1 denoting your highest preference and 4 denoting your lowest preference:
Summer C: 8/31-9/25/15: ______
Autumn A: 9/28-10/23/15: ______
Autumn B: 10/26-11/20/15: ______
Autumn C: 11/23-12/18/15: ______
Section 3: Supplementary Application Checklist
In addition to completing this application form, please submit the following items:
Personal statement discussing career goals
One letter of recommendation (preferably from a pediatric attending)
Curriculum vitae
Official medical school transcript
Complete University of Washington School of Medicine’s visiting student clinical elective application
*It is strongly recommended that the Visiting Student Clinical Elective application be started prior to the acceptance as to not delay the start of the rotation
· http://uwmedicine.washington.edu/EDUCATION/MD-PROGRAM/VISITING-STUDENTS/
Application deadline is July 6, 2015
Please send all application materials to:
Residency Diversity Committee
Email: (subject line: diversity acting internship)