Sub-Internship Application

*All fields are required

Name:

First

Last

E-mail:

Phone:

Area Code

-

Phone Number

Secondary Phone:

Area Code

-

Phone Number

Address:

Street AddressCityState / Province / RegionPostal / Zip Code

Medical School:

Current year in school:

Preferred Sub-internship date:

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?

yes

no

Do you need a place to stay?

yes

no

Are you applying for residency here?

yes

no

Are you a U.S. Citizen or Permanent Resident?

yes

no