DIRECTIONS: Complete all sections of this form. Complete the required health form. Click here.  Enclose a check for $50
non-refundable Application Fee (Payable to MUSC COM) and a copy of your transcript.  DO NOT SEND INCOMPLETE APPLICATIONS.

Student's Name:________________________________________SS#:____________________ DOB:____________________

Address:___________________________________________________Home Phone#:__________________________________

City, State, & Zip Code:___________________________________________________E-mail______________________________
(Must Be Legible or Application Will Be Returned)

Medical School: Present Year in Curriculum:_________________________ Date of Graduation:______________________________

CHECK BOXES FOR CORE CLERKSHIPS YOU WILL HAVE COMPLETED AT THE TIME YOU BEGIN THE ELECTIVE:

  Internal Medicine — Surgery — Pediatrics—  OB/GYN—  Psychiatry — Family Medicine — Other ______________ 

Elective Request: 1st Choice:_____________________________________Course #:_____________________________________

2nd Choice:__________________________________________________Course #:_____________________________________

Dates (MUST COINCIDE WITH MUSC COM CALENDAR - http://www.musc.edu/comelectives/Sr_Calendar.html)

1st Choice:_____________________________________________2nd Choice:___________________________________

Student Signature:_____________________________________________Date:________________________________________

Medical School:____________________________________________________________________________________________

Address:__________________________________________________City_______________________State______Zip________

TO BE COMPLETED BY THE APPLICANT’S MEDICAL SCHOOL DEAN OR DESIGNEE

I hereby certify the above named student is in good academic standing at this institution YES NO
The student has been instructed in the safety and precautions for infection control and has received HIPAA Training YES NO
Medical liability and/or malpractice insurance will be covered by the home school during this elective time    YES NO 
Personal health insurance is in effect during this elective time period. YES NO
I confirm that the student has/will have completed the core clerkships indicated above before the rotation begins YES NO

IF THE ANSWER TO ANY OF THE ABOVE IS NO, STUDENT CANNOT APPLY 

DEAN OR DESIGNEE:(Print Name)___________________________________________ TITLE:_________________________

SIGNATURE:____________________________________DATE:_____________PHONE:___________________________