Visiting Senior Elective Application 2017-2018

Release 58 - 03/29/2017

Each application is for ONE quarter only. Applications received outside the application acceptance periods will NOT be processed. Do not mail applications before the first day of each acceptance period.

Last Name
First Name:
E-mail:
Home address:
City: State: Zip:
Phone Number:
Citizenship:
Birthdate: 19
Sex: Male Female
Ethnicity:

*If you selected other from above please specify
Social Security Number:
Home school:


List your choices in order of preference. Indicate the name, number, and period for each elective. Give alternatives if possible. If you desire a 2-week clerkship, please handwrite it on this form. Indicate whether you want the "Section A" (first two weeks) or "Section B" (second two weeks) of the clerkship. If it is not specified, you will be assigned to either section or both, depending on availability.


Summer Quarter

(Periods 1, 2, 3): Application Acceptance Period: April 1st to April 30th
First choice: Clerkship during
Second choice: Clerkship during
Third choice: Clerkship during
Fourth choice: Clerkship during
Fifth choice: Clerkship during
Total number of desired Summer clerkships:

Autumn Quarter

(Periods 4, 5, 6): Application Acceptance Period: July 1st to July 31st
First choice: Clerkship during
Second choice: Clerkship during
Third choice: Clerkship during
Fourth choice: Clerkship during
Fifth choice: Clerkship during
Total number of desired Autumn clerkships:

Winter Quarter

(Periods 7, 8, 9): Application Acceptance Period: October 1st to October 31st
First choice: Clerkship during
Second choice: Clerkship during
Third choice: Clerkship during
Fourth choice: Clerkship during
Fifth choice: Clerkship during
Total number of desired Winter clerkships:

Spring Quarter

(Periods 10, 11, 12): Application Acceptance Period: January 1st to January 31st
First choice: Clerkship during
Second choice: Clerkship during
Third choice: Clerkship during
Fourth choice: Clerkship during
Fifth choice: Clerkship during
Total number of desired Spring clerkships:

 

Please print this page and send it along with all supporting documentation by mail to:

Clerkship Office
Office of Medical Student Affairs
Stanford University School of Medicine
1265 Welch Road, MSOB X1C48
Stanford, CA 94305-5404