Medical Internship Application Spring & Summer 2019
Please fill out this form to apply for your medical internship, which includes SLHS 882 + SLHS 712. It is essential that you complete this form by the deadline: Wednesday, August 29, 2018 by 4 pm.

**You must have taken the following prerequisites: SLHS 701, 705, 706, 707, 708, 709, 710, 756, 768.
**You must also have completed at least two SLHS 880 (on-campus) clinics. At least one of these clinics must be an adult clinic.
**You must have taken or be concurrently enrolled in SLHS 884 (diagnostic clinic).
**The SLHS 712 seminar meeting time is TBA.
(For detailed information on preparing for the medical internship, see http://slhs.sfsu.edu/gradadvising#medical.)

First Name *
Your answer
Last Name *
Your answer
SFSU Email Address *
Your answer
Phone Number *
Your answer
What is your expected date of graduation? *
I am applying for: *
Site Preferences
We will consider your preferences, but there is no guarantee that you will obtain an internship at your preferred site. Please also keep in mind that pediatric inpatient sites are rare.
I would prefer to work with: *
Please mark the following sites in order of your preference: (1 = most preferred, 7 = least preferred) *
Inpatient hospital adult
Outpatient hospital adult
Skilled nursing facility adult
Private practice adults
Private practice pediatric
Inpatient hospital pediatric
Outpatient hospital pediatric
1
2
3
4
5
6
7
Are you participating in a training grant? *
What classes do you plan to take concurrently with your Medical Internship? Please note that you are required to keep your schedule clear Monday-Thursdays 9 am – 5 pm during the internship. *
Your answer
Do you speak any languages other than English? If so, please write the language(s) below & describe your proficiency in each language. Please also indicate if you would like to be placed in a setting where you can use the language(s).
Your answer
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service