AGMC Medical Educations: Senior Elective Request

ELECTIVE REQUEST

(To be printed out and completed by the student's college of medicine. The medical college should send this to:
Akron General Medical Center Dept. of Medical Education, 400 Wabash Avenue, Akron, OH 44307.)

(Name) __________________________________, a _____________-year medical student enrolled in

_____________________________________ College of Medicine, has been granted an elective at

Akron General Medical Center in the Department of _______________________, from

(Date) ________________________________ to (Date) ________________________________.

__ Yes __ No___A. The University's student malpractice insurance covers the student during this elective.

__ Yes __ No___B. Student personal health coverage is in effect during this period.

__ Yes __ No___C. Student's immunization is current, which includes Rubella, Rubeola, Mumps,
_______________Varicella and Hepatitis B. Documentation can be produced upon request.

__ Yes __ No___D. There is a standard evaluation form which we will mail to you.

Comments

_________________________________________________________________________________

Name (Typed) __________________________________ Address____________________________

City ____________________________________ State ________________ Zip _________________

Signature ________________________________________ Date ____________________________

Title _____________________________________________________________________________