Medical Student EM Rotation Request
Please complete this form to request your rotation. All requests MUST be submitted on or after the open application date. Once your request is processed, you will be notified via email if your request has been approved or denied. ROTATIONS ARE SUBJECT TO CANCELLATION IF YOUR SCHOOL PAPERWORK IS NOT RECEIVED. Only ONE REQUEST per application will be accepted.
Email address *
PERSONAL INFORMATION
Name (Last) *
Your answer
Name (First) *
Your answer
Home Address *
Your answer
Contact Phone Number *
Your answer
DOB *
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SSN - Last 4 Digits *
Your answer
MS Year When on Rotation at ARMC *
MEDICAL SCHOOL INFORMATION
School Name/Campus *
Your answer
School Coordinator *
Your answer
Coordinator's Email *
Your answer
ROTATION REQUESTS
Rotations start every Monday and 4 weeks long. If your 1st choice of rotation dates is unavailable, your 2nd and 3rd choices will be considered.
1st Rotation Date Requested *
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2nd Rotation Date Requested
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YYYY
3rd Rotation Date Requested
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DD
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YYYY
Purpose of Rotation *
Days off Needed (Eg: Board Exams, Campus Days, etc. NO HOLIDAYS. All days off requested are PENDING APPROVAL.) *
Your answer
A copy of your responses will be emailed to the address you provided.
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