Sub-Internship Application *All fields are requiredName: First Last E-mail:Phone: Area Code - Phone Number Secondary Phone: Area Code - Phone Number Address: Street AddressCityState / Province / RegionPostal / Zip CodeMedical School: Current year in school: Preferred Sub-internship date:First Choice:7/30/18 – 8/24/188/27/18 – 9/21/189/24/18 – 10/19/1810/22/18 – 11/16/1811/19/18 – 12/14/181/07/19 – 2/01/19 Second Choice:7/30/18 – 8/24/188/27/18 – 9/21/189/24/18 – 10/19/1810/22/18 – 11/16/1811/19/18 – 12/14/181/07/19 – 2/01/19 Tell us about your interest in family medicine:List the learning objectives for your sub-internship in your own words (Do not list your school's objectives):Do you have family or other ties to the Yakima area?yesnoDo you need a place to stay?yesnoAre you applying for residency here?yesnoAre you a U.S. Citizen or Permanent Resident?yesnoOnce you have submitted this form you should receive an email confirmation that it has been submitted successfully.SubmitReset
