INTERNATIONAL VISITING MEDICAL STUDENT PROGRAM APPLICATION (Part 1) Page 1 To be completed by the Visiting Medical Student.

Transcription

1 Please DO NOT staple the application pages or supporting documents. Only paperclip. INTERNATIONAL VISITING MEDICAL STUDENT PROGRAM APPLICATION (Part 1) Page 1 To be completed by the Visiting Medical Student. Birth Date (mm/dd/yy): Telephone: Gender (circle): Male Female Citizenship: Mailing Address: Citizenship Country: Address: Medical School: Expected Degree: Medical School Address: Year in Program: Expected Degree Date (mm/dd/yy): Medical School Contact: Contact Phone: Contact Address: Name and Address of Emergency Contact Person: Emergency Contact Phone: TO BE ELIGIBLE FOR CONSIDERATION, all visiting students must submit the entire Application (pages 1-4) to the Registrar s Office together with the following documents: 1. Photograph Must be in color, must not exceed 2 x 2-inches in size. 2. Curriculum Vitae 3. Documented proof of passing USMLE Step 1 score; this is mandatory no exceptions! 4. Official transcript from medical school 5. U S Money Order for $125.00, per elective being requested (maximum 2 electives for $250.00) 6. If accepted for a rotation, international students must provide proof of valid visa status (you may fax or a copy of your passport Visa page) a) Documented Proof of Personal Health Insurance (copy of insurance card with coverage dates is accepted) b) And Documented Proof of Professional Liability Insurance ($1,000,000 per claim/$3,000,000 aggregate); and c) Completed immunization form. (located on webpage) (initials) (initials) I understand that all items 1-5 above must be submitted together in ONE packet, otherwise my application will be considered incomplete and may result in my not being considered for an elective. I acknowledge that I am currently enrolled in the Medical School that is verifying my application, currently in my last year of Medical School, and graduating within 12 months of placement. Signature:

2 INTERNATIONAL VISITING MEDICAL STUDENT PROGRAM APPLICATION (Part 2) Page 2 To be completed by Dean of Student or designated official at medical school where the Visiting Student is enrolled. Student is approved to do electives away from home school for academic credit: (circle): Yes No Student will be enrolled as a 4 th or final year med student at home school at time of elective rotation (circle): Yes No Student is in good academic standing at home school (circle): Yes No Student has taken and passed Step 1 of the USMLE, documented proof required. (circle): Yes No Student will be covered by malpractice insurance while away (circle): (Minimum $1 million/$3 million aggregate - documented proof required). Yes No Student will be covered by personal health insurance while away (circle) (documented proof required): Yes No Will the medical school accept the LSUHSC Shreveport Evaluation Form in lieu of their own form? If not, please provide the medical school evaluation form with this application. Yes No HOME SCHOOL VERIFICATION: To be completed by Dean or Registrar Authorized by (signature): Name (print or type): Title Home Medical School: Address: School Seal Telephone: Address: AN EMBOSSED SCHOOL SEAL IS PREFERRED. IF INSTITUTION DOES NOT POSSESS ONE, PLEASE HAVE AUTHORIZED INDIVIDUAL INITIAL BY THE OFFICIAL STAMP.

3 Please DO NOT staple the application pages or supporting documents. Only paperclip. VISITING MEDICAL STUDENT PROGRAM APPLICATION (Elective Request Form) Page 3 Choose up to a maximum of 2 electives, scheduled in 4-week blocks only (refer to Academic Calendar on Page 5). Visiting Medical Students are not scheduled for more than 2 electives for a total of 8 weeks. Please refer to the List of Electives and Academic Calendar when submitting your request. Please add an additional form if you are choosing blocks Do not add blocks 7-11 to this form if you want an elective for blocks 5 and 6. REQUESTED ROTATIONS: Elective 1: Preferred Block Alternate Block Elective 2: Preferred Block Alternate Block NOTICE: We charge a NON-REFUNDABLE application processing fee of $125 for each elective that you request (maximum of 2 electives for $250). This processing fee is not dependent on being offered an elective. 1 Elective = $125 2 Electives = $250 I understand that the scheduling of elective rotations is done on a competitive basis and that I may not get the elective(s) that I am requesting on this form. I understand that I will be charged an application processing fee of $ for each elective that I request and that this fee is non-refundable, regardless of whether or not I am offered or accept an elective. I understand that confirmation of acceptance into any elective cannot be given until after LSUHSC-S students have been scheduled. If scheduled for an elective, I agree to notify the Office of the Registrar a minimum of 30-days prior to the start of my scheduled rotation Block should I not be able to do the elective. I understand LSUHSC-S has a 30-day cancellation policy, and if I cancel an elective within the 30-days the elective cannot be rescheduled and my other pre-arranged electives may also be cancelled. I understand if I am offered and have accepted an elective at LSUHSC-S, I will provide the required immunization form, supporting documents, proof of professional liability insurance, proof of health insurance and if applicable, proof of valid visa status within 2 weeks of accepting offer; otherwise, failure to receive these items in a timely manner may result in my elective to be cancelled. Signature of Applicant:

4 Page 4 Visiting Student Payment Form NOTICE: We charge a NON-REFUNDABLE application processing fee of $125 for each elective that you request (maximum of 2 electives for $250). This processing fee is not dependent on being offered an elective. 1 Elective = $125 2 Electives = $250 Visiting Student Name: Please make Money Order (US dollars only) payable to LSUHSC. Please paperclip your payment to your application. If payment is not included with your application, your application will be denied.

5 Page 5 AC ADEMIC CALENDAR NOTE: All Visit ing S tudents electi ves ar e 4 -w eek rotations ONLY. Curriculum Block Dates Block 1 7/3/17 7/28/17 Block 2 7/31/17 8/25/17 Block 3 8/28/17 9/22/17 Block 4 9/25/17 10/20/17 Block 5 10/23/17 11/17/17 Block 6 11/20/17 12/15/17 Block 7 1/3/18 1/26/18 Block 8 1/29/18 2/23/18 Block 9 2/26/18 3/23/18 Block 10 3/26/18 4/20/18 Block 11 4/23/18 5/18/18 Visiting student applications will not be processed for blocks 1-4 due to no vacancies in any department. Applications for electives from blocks 5-6 will be accepted and processed only starting on June 1, Applications for electives from blocks 7-11 will be accepted and processed starting on September 1, Applications received prior to this date for blocks 7-11 will not be processed. Applications for electives starting in or after July 2018 are not currently being accepted.