Tufts University School Of Medicine


	Tufts University School Of Medicine
	2009-10 VISITING STUDENT PROGRAM APPLICATION

Name:	SID#:	Date:
Address:	E-Mail:
	Phone:	Citizenship:
School:		Exp. Grad:
Address:		(MM/YY)
Optional questions:	Gender:	Race/Ethnicity:

This application cannot be processed without the following items: current transcript, check or money order for $75.00 (per elective block), TUSM Visiting Student Immunization Form, and copy of health insurance card.

Please list electives in order of preference. You may attach additional selections. Please refer to the 4th Yr Elective Dates calendar for Block numbers and dates:
Title:	Code #:	Block #:
Title:	Code #:	Block #:
Title:	Code #:	Block #:
I attest that the information provided and the materials submitted are true and accurate. I also agree that, if scheduled for an elective, I will abide by all TUSM policies.
Signature:

TO BE COMPLETED BY THE DEAN FOR STUDENTS
OR AUTHORIZED OFFICIAL OF APPLICANT'S MEDICAL SCHOOL

The above named student is a final year student in good standing at the above mentioned LCME accredited medical school.	YES	NO
He/She will pay tuition at his/her home school during this elective period.	YES	NO
This student is covered by malpractice/liability insurance while away from his/her medical school.	YES	NO
This student is covered by personal health insurance while away from his/her medical school. Please attach copy of card.	YES	NO
This student has completed education in universal precautions within twelve months of the start of this elective.	YES	NO
This student will be taking this elective for credit.	YES	NO
This student has taken and passed the USMLE Step I Exam	YES	NO

Please Note: A Tufts evaluation form will be submitted.
Signature:	Date:
Name/Title:	Phone:	( )
(School Seal Required)

Return this application and required items at least one month before the rotation start to:

Clerkship Coordinator
Tufts University School of Medicine
Registrar's Office, Sackler Bldg.
145 Harrison Avenue
Boston, MA 02111
( 617/636-6568