Sub-Internship Application

Personal Details

All fields are required

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Are You a U.S. Citizen or Permanent Resident? *

Yes
No

Have You Received a COVID-19 Vaccination? *

Yes
No

Emergency Contact *

First

Last

Emergency Contact Phone *

Medical School Details

All fields are required

Medical School *

Current Year In School *

Have You Passed Step 1/COMLEX Level 1 With No More Than One Examination Failure? *

Yes
No

Rotation Options

All fields are required

What is Your Preferred Rotation Date (First Choice)? *

What is Your Preferred Rotation Date (Second Choice)? *

Interests

All fields are required

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 Interested in the Ellensburg Rural Program? *

Yes
No

Our Ellensburg Rural Program is not offering full rotations, however, we can build some time into your Yakima schedule to visit Ellensburg for specific program activities.

Sub-Internship Application

Personal Details

Medical School Details

Rotation Options

Interests

Once you have submitted this form you should receive an email confirmation that it has been submitted successfully.