Medical Student EM Rotation Request

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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 *

PERSONAL INFORMATION

Name (Last) *

Name (First) *

Home Address *

Contact Phone Number *

DOB *

YYYY

SSN - Last 4 Digits *

MS Year When on Rotation at ARMC *

MS-III

MS-IV

MEDICAL SCHOOL INFORMATION

School Name/Campus *

School Coordinator *

Coordinator's Email *

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 *

YYYY

2nd Rotation Date Requested

YYYY

3rd Rotation Date Requested

YYYY

Purpose of Rotation *

Elective

SUB-I

Audition

Days off Needed (Eg: Board Exams, Campus Days, etc. NO HOLIDAYS. All days off requested are PENDING APPROVAL.) *

A copy of your responses will be emailed to the address you provided.

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