Clinical Internship Application
Transcription
Clinical Internship Application
Clinical Internship Application Burnett School of Biomedical Sciences College of Medicine Attach Picture Name: ________________________________________________________________ PID: _____________________ Date of Birth: ___________________ Sex: ________ Phone: ________________________________ Email: ____________________________________________ Address: __________________________________________________________________________________ Emergency Contact: _________________________________ Phone: ________________________________ Major(s): ______________________________________ Overall GPA1: __________ 1 UCF GPA1: __________ GPAs are listed on your Degree Audit next to #1/#4 in the University Credit Hour Requirements section Credits at UCF2: __________ 2 Total Credits: __________ Graduation Month/Year: _____________________ 30 completed credits at UCF are required by the start date of the internship Grade in3: 3 Human Anatomy (ZOO 3733C): _____________ Human Physiology (PCB 3703C): _____________ If currently enrolled, enter expected grade with an asterix. If future enrollment, enter semester you will be taking the class I am applying for internships in (check one only) Fall Spring Have you previously completed a BSBS Clinical Internship? Yes No Which? __________________ Have you previously interviewed for the Surgical Internship? Yes No Would you participate in an internship that uses Note other languages you are fluent in: _________________ this language to see patients? Yes No Prior to selecting internships, please see the “Description and Selection Criteria” document for specific information about each program, program requirements (such as minimum GPA, weekly hours required, expenses, and other expectations), and selection criteria. Please rank the internships for which you would like to be considered, using numbers such as “1” and “2”. You will be reviewed primarily on your first choice, followed by your second choice. You will be considered for third/fourth choice only if there are no competitive applicants for those positions. Only choose internships that you wish to participate in if accepted. Please note, there are usually 110+ applicants for ~40 positions. _______ Surgical Internship at Florida Hospital > 3.5 UCF GPA? Yes No > 3.3 UCF GPA? Yes No > 3.3 UCF GPA? Yes No Yes No ~3 positions, interview required late Aug. or early Dec. Minimum of 4-6 hours/week, flexible schedule, commuting, Florida Hospital expenses _______ Private Practice Clinical Internship ~15-20 positions, 4 hours/week, commuting _______ Osteopathic Family Practice Clinical Internship ~4 positions, 4 hours/week MTRF PM, commuting, Florida Hospital expenses _______ Clinical Research Internship at Florida Hospital ~14 positions. Apply in Fall only for the entire Fall/Spring course 4-8 hours/week, commuting, Florida Hospital expenses > 3.5 UCF GPA? QBM Grade: _____ Application Status: Mark all the professional schools to which you may apply to or pursue: Medical (Allopathic) Nursing Dentistry PT/OT Medical (Osteopathic) Nurse Practitioner Optometry Podiatry Physician Assistant Chiropractic Pharmacy Public Health Graduate Veterinary Other (list): Would you be willing to shadow a Physician Assistant for part of the internship? Have you taken the MCAT? _________ Yes No If accepted, what year would you begin Medical School? __________ Have you applied to Medical School? _________ If yes, what is the status (accepted, pending)? ____________ If no, when will you be applying4? _____________________ 4 typically the summer after your Junior year What medical specialties are you interested in pursuing? ___________________________________________ List other professional school applications and status: ______________________________________________ Experience: Please accurately list and briefly describe all prior and current internship, shadowing, research, and health care delivery experiences, including total hours for each: Statement of Purpose: Briefly describe why would you like to complete a clinical internship in medicine: Availability: Internships have specific time requirements. Surgical requires morning availability, but times may vary weekly depending on the assigned doctor, other days and times may work. Osteopathic requires one 4 hour block weekly, on MTRF afternoons. Private Practice prefers one 4 hour block but two 2 hour blocks weekly is an option. Clinical Research has specific time requirements in fall (~8-10:30) but is more flexible in spring. You can mark days that currently conflict with your schedule if you are willing to move or drop the class if accepted. Please consider commuting times to and from the location: Can you rearrange your schedule to accommodate shadowing if necessary? Yes No Note () your approximate availability for the internships to which you are applying. All internships require a commute, therefore having a class immediately before/after a time slot may not work: Surgical, Private Practice, Osteopathic (Please see Description and Selection Criteria document): Monday Tuesday Wednesday Thursday Friday AM (8-12 or 9-1) Mid-Day (10-2 or 11-3) PM (12-4 or 1-5) Clinical Research Internship: Fall: Spring: Tuesday ~8:00-10:30 AM 6-8 hours/week of availability for research Commuting: Can you commute? Yes No Note () locations to which you can commute for the internships to which you are applying. Willingness to commute further distances can make you a stronger applicant for certain internships: Surgical: Downtown Orlando Clinical Research Internship: Florida Hospital (Downtown Orlando) Osteopathic Family Practice: Florida Hospital East Private Practice: UCF Area, Oviedo, Waterford Downtown Orlando, Winter Park North: Altamonte Lake Mary Sanford Deland/Orange City South: Lake Nona Kissimmee West: Apopka/Ocoee Grades: Attach a list of your grades. The “course summary” view that lists all courses and grades neatly is preferred. An unofficial transcript is acceptable. Degree audits are difficult to read and not preferred. Highlight major and science courses. Note expected grades of courses in which you are currently enrolled. Involvement: Attach a CV, resume, or list of involvement including experiences, shadowing, research, clubs, leadership positions, etc., including locations and total hours for each when relevant. Schedule: Attach your course schedule (“weekly view”) for the semester to which you are applying. Note any classes that are flexible in the event that you are selected for an internship. Please contact Dr. Robert Borgon ([email protected]) or Dr. Genaro Lopez ([email protected]) for application or program questions. Submit or mail your application to 4364 Scorpius St., HPA2 Room 335, Orlando, FL 32816-2360