Application - Clinical/Scholarly Experience for UT M1s

Exit Survey

Questions marked with a * are required

100%

Contact Information

First Name

Last Name

Middle Name

Phone

Birth Date. (MM/DD/YYYY)

Email Address

Street Address

City

State

Zip Code

Gender

Male

Female

Are you a UTHSC College of Medicine student?

Yes

Are you a UTHSC M1 student?

Yes

What year will you graduate medical school?

Department Opportunities

Opportunities are available in Emergency Medicine, Family Medicine, Neurology, Surgery, and Urology.

Enter your 1st choice of department opportunities from the above list.

Enter your 2nd choice of department opportunities from the above list.

Beginning date you are available for the immersion experience:

Ending date you would be available for the immersion experience:

Please list any medical condition(s) of which we should be aware.

Emergency Contact Information

First Name

Last Name

Phone

Relationship

If a bedroom were available in the apartments leased for students, would you like to request housing with us?

Yes

Note: Housing is not available for spouses or families of students.

Documentation Required (in addition to this online application):

Current CV
Email your photo (headshot) as a .jpg or .png file
Statement of interest about the program in a one-page narrative (400 words or less)
Immunization record with proof of MMR, chickenpox immunity, and negative TB skin test within the past 12 months
Copy of HIPAA training from UTHSC
Copy of CITI Certificate from UTHSC
Letter of good academic academic standing from the Office of Medical Education at UTHSC Memphis

Required documentation should be emailed to [email protected].

Questions: If you have questions about the immersion experience or your application, please contact the Office of Graduate and Medical Student Education in Chattanooga at 423.778.7442 or email [email protected].