Pre-Med Internship Volunteer Program
June 2, 2015 – July 24, 2015
Purpose:This program is designed for students who plan to enter medical profession with primary focus on physician study. It will provide pre-med students a practical and valuable opportunity to participate in a supervised, prescribed program of inservice training and volunteer service in the medical field.
To allow pre-med students the opportunity to evaluate their commitment to medicine as
a career.
This eight-week program includes hospital orientation, clinical rotation, and opportunity for observation.
Clinical Rotation includes but is not limited to:
Behavioral HealthRadiology
Emergency DepartmentResident Physician Rotation
Clinical Process ImprovementRespiratory Care
DialysisSystem Affiliate Hospital
G.I. LabSurgery
Laboratory/PathologyPharmacy
Med Center EMS
Tennessee Heart CenterKirkland Cancer Center
Cath LabHospice
CardiologyOncology Nursing
Cardiac RehabRadiation Oncology
EKGWestTennesseeRehabilitationCenter
Women and Children’s CenterPhysical Therapy
Labor and DeliverySports Medicine
PediatricsRehabilitation Services
Mother/Baby Unit
Eligibility:
Complete Sophomore Year by June 1, 2015
Plan to enter medical profession with primary focus on physician study
Have a cumulative 3.3 G.P.A.
Enrollment limited to ten (10-14) participants
*Your OFFICIALTranscript must be mailed directly from the schoolTranscript must be received by deadline date: March 6, 2015!!!
*Please note: We will notify you through the email address that you
provide whether you have been selected or not.
Application Information:
Heather Cavnessat (731) 423-1932 (Ext. 262)
Application and Transcript Deadline~ March 6, 2015
Mail completed application to:
UTFamily Medicine
Heather Cavness
Admin. Recruiting Coordinator
294 Summar Drive
Jackson, TN 38301
E-mail:
APPLICATION FOR PRE-MED INTERNSHIP VOLUNTEER PROGRAM
Applicant’s Full Name
Home Address School Address
City State Zip City State Zip
Telephone Cell Phone Number
Social Security Number E-Mail Address
E-Mail Address you most often check
EDUCATION:
High School:
Name of School: Grade Completed:
Course of Study: Type of Diploma:
College:
Name of College: ______Year Completed: ______
Major/Minor: ______Degree Received: ______
Future Educational/Career Plans:
List any honors and/or awards earned, or offices held in High School or College:
List of school activities, hobbies, and interests; offices held, etc:
EMPLOYMENT:
Name of Employer / Duties / Dates / Reason for leaving1.
2.
3.
In Case of Emergency: Name Phone
Relationship Address
In your Own Words, Give Your Reasons for Wanting to Participate In This Program
PERSONAL REFERENCES (other than relatives)
(The names you list below MUST be who we receive recommendation letters from)
Name / Address / Phone1.
2.
3.
PERSONAL REFERENCE/RECOMMENDATON LETTERS: One (1) letter must be from a teacher/professor, one (1) must be from a professional, and one (1) must be a personal reference/recommendation. These letters can be e-mailed to Heather Cavness @ ; and must be as an attachment on letterhead. These letters can also be mailed. All letters must be received by deadline date ~ (March 6, 2015).
Are you a United States Citizen?
Yes / NoNote: Answering “no” to this question does not constitute an automatic bar from volunteering.
Within the past 7 years, have you either been (1) convicted by any court, including a court of military justice, or a felony, or (2) been released from prison following conviction of a felony? (For purposes of this application, consider felonies to include any crime that is punishable by imprisonment or execution).
Yes / NoNote: Answering “yes” to this question does not constitute an automatic bar from volunteering.
If yes, state date, place, and nature of each conviction
I hereby certify that all answers given by me on this application are true to the best of my knowledge. I authorize
UTFP to contact references whom I have listed on this application for the purpose of acquiring information about me; and I release UFP and anyone releasing information to UTFP from any liability based upon such release.
Date Signature