Physical Medicine and Rehabilitation - Medical Students Application

Physical Medicine and Rehabilitation Elective
UPMC Mercy
1400 Locust Street
Pittsburgh PA 15219

Telephone: 412-864-3721
Fax: 412-692-4410
Shana Heald
E-mail: Residency Program Coordinator

Demographic Information Form

* = Required Fields

I, , wish to apply for a clinical rotation at UPMC Mercy and attest to the truthfulness of the information below.

STUDENT INFORMATION

*Student Name:  DOB:

*Mailing Address:  *City:  *State: *Zip:

*Telephone #:  Cell/Pager:  E-mail Address:

Requested Date(s) of Rotation:

Career Interest(s) Include:

Choice 1:

to

Choice 2:

to

Choice 3:

to

Internal Medicine

Neurology

Orthopedics

PM&R

Rheumatology

Other:

*In 100 words or less, why are you interested in doing a PM&R rotation at UPMC Mercy? Your expectations/goals/interests?

MEDICAL SCHOOL INFORMATION

Medical School:  LCME#:

School Address:  City:  State:  Zip:

DEAN'S OFFICE CONTACT

Name:

Mailing Address:  City:  State:  Zip:

Telephone #:   Fax:  Email Address:

EMERGENCY CONTACT INFORMATION

Contact #1
Name:  Relationship:

Telephone #:  Cell:  Email Address:

Contact#2
Name:  Relationship:

Telephone #:  Cell:  Email Address: