ࡱ> jmiq  @bjbj |btiZjtiZj ~~|'xw&y&y&y&y&y&y& )+y&Q!N@!!y&&$$$!Rw&$!w&$$c"$x{!F$c&&0'$B,!B,$B,$l$ >b ,$ $ $ $ $ y&y&"$ $ $ '!!!!B,$ $ $ $ $ $ $ $ $ ~Y : MEMORIAL MEDICAL CENTER REQUIREMENTS FOR MEDICAL STUDENT ROTATION MEDICAL STUDENT S FULL NAMEToday s Date:  FORMTEXT      LAST:  FORMTEXT      FIRST :  FORMTEXT      MIDDLE:  FORMTEXT      ADDRESS:  FORMTEXT      PHONE NUMBER:  FORMTEXT      CELL PHONE: FORMTEXT      EMAIL:  FORMTEXT      HOMETOWN:  FORMTEXT      EMERGENCY CONTACT:  FORMTEXT      PHONE # FORMTEXT      GENDER:  FORMCHECKBOX  M  FORMCHECKBOX  FMS 4  FORMCHECKBOX   FORMCHECKBOX  must have completed a Surgery and IM RotationYEAR OF GRADUATION:  FORMTEXT      SPECIALTY INTEREST:  FORMTEXT      DATES OF REQUESTED ROTATIONDoes your school have a HOME EM residency Program?  FORMCHECKBOX  Yes  FORMCHECKBOX NoNumber of EM Rotations Scheduled:  FORMTEXT      #1. ROTATION DATES: START DATE:  FORMTEXT      END DATE:  FORMTEXT      #2. ROTATION DATES: START DATE:  FORMTEXT      END DATE:  FORMTEXT      #3. ROTATION DATES: START DATE:  FORMTEXT      END DATE:  FORMTEXT      MEDICAL SCHOOL:  FORMTEXT      ADDRESS:  FORMTEXT       STATE:  FORMTEXT      CLINICAL COORDINATOR/CONTACT:  FORMTEXT       PHONE NUMBER:  F.0Rp     & ( * ɿxxxxxkcSkjhUhx@5UhUhx@5jhUhx@5U#jhPh!t5UmHnHujhPhT5UhPh!t5jhPh!t5Uh!thx@h|h7~h!t5B*phh|5B*phh7~5B*phh>* h!t5B*phhnU]hCJ$aJ$hnU]h!tCJ$aJ$0  8 r |Xkdt$$Ifl0L*' t'644 laytx_ $Ifgd!t $Ifgdx_$-D@M a$gdnU]$a$gd!t* , . 0 2 4 6 8 B J L ` b d f h j l n p r    óסÑסÁסjhUhx@5UjhUhT5U#jhUhx@5UmHnHujGhUhT5UhUhx@5h_mhx@h!tjhUhx@5U6jhUhx@5OJPJQJU^JmHnHo(u2 , j D; $Ifgdx@Ekd $$Ifl*'' t'644 laytP $Ifgd!tkkd/$$IflzFv*'L  t'6    44 layt   " $ & ( * , B D X Z \ ^ ` b d f h j x z ŵť͡xjhUh05UhUh>* 5jhUh>* 5Uh>* hUj=hUhT5UjhUhT5UhUhx@5hx@#jhUhx@5UmHnHujhUhx@5UjUhUhT5U( 0 f DEkd$$Iflp*'' t'644 laytP $Ifgd!tkkd$$IflFv*'L  t'6    44 laytP   " $ & ( * , . 0 > @ T V X Z \ ^ ` b d f h z | óˡؖppppphjh|U jhUh|UmHnHujOhUh{U hUh|jhUh|U#jhUh|5UmHnHujhUh|5UhUh|5jhUh|5Uh|h>* jhUh>* 5U#jhUh>* 5UmHnHu$f h  ;Xkd$$Iflp0*'0f t'644 laytD $Ifgd7~ $Ifgd!tXkd$$Iflp0*'$r t'644 laytP   " $ & , 6 8 訠zozaaaaazjh/.UmHnHujM h/.Ujh/.Uh/.hDhDCJaJj~hDCJUaJhDCJaJjhDCJUaJj h{Uh7~jhPh{5UhPh|5jhPh|5Uh|jh|Ujh{U% . 0 2 4 l ?Ukd $$Ifl*'' ` t 1'644 lap 1ytXkd9 $$Ifl^0*'Z< t'644 laytU $Ifgd!t $Ifgd/.      " $ & ( * , . 0 2 4 j l n  "$(*np󵩵qj9 hCJUaJhhCJaJj hCJUaJjM hCJUaJjhCJUaJhCJaJh/.h/.5>*hh/.CJaJjh/.UmHnHuj h/.Ujh/.Uh/.hDh/.5%l n *DWXkd $$Ifl04*' t'644 layt $Ifgd/.Ekd $$Ifl_*'' t'644 layt2468:<>@BDFº˜º˜ºx˜jMhUh/.5Uj~ hUh/.5U#jhUh/.5UmHnHuj hUh/.5UhUh/.5jhUh/.5Uh/.hhhCJaJjhCJUaJ"jhCJUaJmHnHu/DFdDXkd9$$Ifl^04*' t'644 laytP $Ifgd/.Xkd $$Ifl^04*' t'644 laytP<>RTVXZ\^`bdxzęjAhUh/.5Uhh/.CJaJjhUh/.5UjhUh/.5Uh/.#jhUh/.5UmHnHujhUh/.5UjhUh/.5UhUh/.56H? $Ifgd7~Ukd$$Ifl*'' @ t '644 lap ytU $Ifgd!tXkd~$$Ifl^04*' t'644 laytP.0ljEkdx$$Iflh*'' t'644 laytU $Ifgd!tEkd$$Ifl*'' t'644 laytU "$&(*,.0DFZ\^`bdfhjln888888888 8H8J8^8jEhUh/.5UUjhUh/.5UjhUh/.5Uh/.#jhUh/.5UmHnHujhUh/.5UjhUh/.5UhUh/.55ln8jEkd$$Ifl^*'' t'644 laytP $Ifgd!tEkd9$$Iflh*'' t'644 laytUORMTEXT       FAX NUMBER:  FORMTEXT       EMAIL:  FORMTEXT      WHAT DREW YOU TO CONEMAUGH FOR YOUR EM ROTATION?  FORMTEXT      WHAT ARE YOUR 3 TOP LEARNING GOALS FOR YOUR MONTH AT CONEMAUGH?1 FORMTEXT      2 FORMTEXT      3 FORMTEXT      RESIDENT REQUIREMENTS PRIOR TO CLINICAL EXPERIENCE FORMCHECKBOX Medical School Transcript (unofficial)  FORMCHECKBOX Comlex or USMLE Scores - Attached FORMCHECKBOX  CV  FORMCHECKBOX must have completed a Surgery and IM Rotation FORMCHECKBOX Must be U.S. Citizen/Permanent US Resident FORMCHECKBOX Background ClearancesComplete this form and email to HYPERLINK "mailto:SEckenro@conemaugh.org"SEckenro@conemaugh.org  Residency Use: Approved __________________ __________ Clerkship Dir Date Student Notified: ______________ Date Shannon Eckenrode, Program Coordinator Emergency Medicine Residency Conemaugh Memorial Medical Center CP1004 1086 Franklin Street Johnstown PA 15905 ^8`8b8d8f8h8j8l8n888888888888888899.90929496989:9<9>9@9B9D9F9^9`999ŵͪͦvvoov hUhUhPhUCJaJjhUmHnHujXhUhjhUhUhh/.CJaJj1hUh/.5UhUh/.5h/.#jhUh/.5UmHnHujhUh/.5UjhUh/.5U*8888@9]T $IfgdSkd$$Ifl*'' @ t '644 lap ytP $Ifgd!tEkd$$Iflz*'' t'644 laytU@9B9D9F99lCkd$$Ifl*'' t'644 laytU $Ifgd!tEkd$$Ifl*'' t'644 laytoc999999":YXkd$$Ifl0h*'% t'644 laytoc $Ifgd!tCkd`$$Ifl*'' t'644 laytU99999999999999999:::::::: :":$:(:*:>:@:B:D:F:H:J:L:N:P:R:T:V:::::::{#jhPhCJUaJjhPhUCJUaJhUhhUCJaJjEh!eUjvh!eU hUhUjh!eUmHnHujh!eUh!ejh!eUhPhUCJaJhUCJaJ0":$:(:P:R:T:D; $IfgdUXkd$$Ifl0h*'% t'644 laytoc $Ifgd!tXkd$$Ifl0h*'% t'644 laytocT:V::::2;_V $IfgdCkdz$$Ifl*'' t'644 laytU $IfgdUSkd$$Ifl*'' ` t 1'644 lap 1ytU::;.;0;2;4;6;R;T;V;X;f;x;;;;;;;;;;;;;;;;;;<~rj[rjP~hDhSkCJaJjh9+CJUaJh9+CJaJjh9+CJUaJhSkCJaJhDCJaJhPhDCJaJjShYCJUaJjhYCJUaJhYCJaJ#jhPhUCJUaJjhPhUCJUaJhscCJaJh CJaJh9+CJaJhPhUCJaJ2;4;X;;;;;H? $IfgdSkVkd$$Ifl0*'# t'644 laytU $IfgdUVkd5$$Ifl0*'# t'644 laytU;;;R<T<x<<H?? $IfgdscVkd$$Ifl0*'# t'644 laytU $IfgdUVkd$$Ifl0*'# t'644 laytU<P<R<T<V<r<t<v<x<<<<<<<<<= ="=$=&=οַ{l{dYNCNhhscCJaJhPhscCJaJhDhscCJaJhscCJaJjhscCJUaJhscCJaJjhscCJUaJhPhBCJaJhochB5CJ\aJ *hochoc5CJ\aJhBCJaJjhocCJUaJhocCJaJjhocCJUaJhPh9+CJaJh9+CJaJhDhSkCJaJ<<< ="=$=HVkd*$$Ifl0*'# t'644 laytU $IfgdscVkd_$$Ifl0*'# t'644 laytU$=&===>$>`>>>>>>>*?d????@@gd!tSkd$$Ifl*'' @ t '644 lap ytP&=(=8=V=h=j=l============>$>>>J>`>>>>>>>>>>?·ʪʢzzzrzzrrrrrznf[hBhx_CJaJhCJaJh/}h/}CJaJh/}h/}CJaJhhx_CJaJ"jhBCJUaJmHnHuh!tCJaJhzih0JCJaJhhCJaJhCJaJjhCJUaJhBCJaJhCJaJhx_CJaJ"jhocCJUaJmHnHu ??*?d????@@ @ @hhx_CJaJh!thx_hBhx_CJaJhBhDCJaJ @ @ @gd!tz+p0 ,p0 -p0 .p0 1h/R 40506070:pz/ =!"F#$% tDText3]$$If!vh#v#v :V l t'6,55 ytx_tDText1tDText4tDText5e$$If!vh#vL#v #v :V lz t'65L5 5 yttDText6I$$If!vh#v':V l t'65'ytPtDText7tDText8tDText9e$$If!vh#vL#v #v :V l t'65L5 5 ytPvDText22I$$If!vh#v':V lp t'65'ytPvDText23vDText24W$$If!vh#v$#vr :V lp t'65$5r ytPvDeCheck12vDeCheck13tDeCheck9vDeCheck14W$$If!vh#v0#vf:V lp t'6505fytDvDText26vDText27W$$If!vh#vZ#v<:V l^ t'65Z5<ytUh$$If!vh#v':V l ` t 1'65'p 1ytO$$If!vh#v':V l_ t'6,5'ytvDeCheck16vDeCheck17vDText32W$$If!vh#v#v:V l t'655ytvDText13vDText14W$$If!vh#v#v:V l^ t'655ytPvDText13vDText14W$$If!vh#v#v:V l^ t'655ytPvDText13vDText14W$$If!vh#v#v:V l^ t'655ytPh$$If!vh#v':V l @ t '65'p ytUvDText20I$$If!vh#v':V l t'65'ytUvDText21I$$If!vh#v':V lh t'65'ytUvDText15I$$If!vh#v':V lh t'65'ytUvDText16I$$If!vh#v':V l^ t'65'ytPvDText17vDText18vDText19I$$If!vh#v':V lz t'65'ytUd$$If!vh#v':V l @ t '65'p ytPvDText28I$$If!vh#v':V l t'65'ytocE$$If!vh#v':V l t'65'ytUE$$If!vh#v':V l t'65'ytUvDFText29W$$If!vh#v#v%:V l t'655%ytocvDFText30W$$If!vh#v#v%:V l t'655%ytocvDFText31W$$If!vh#v#v%:V l t'655%ytocd$$If!vh#v':V l ` t 1'65'p 1ytUE$$If!vh#v':V l t'65'ytUtDCheck1S$$If!vh#v#v#:V l t'655#ytUtDeCheck4S$$If!vh#v#v#:V l t'655#ytUvDeCheck15S$$If!vh#v#v#:V l t'655#ytUvDeCheck15S$$If!vh#v#v#:V l t'655#ytUvDeCheck15S$$If!vh#v#v#:V l t'655#ytUvDeCheck15S$$If!vh#v#v#:V l t'655#ytUd$$If!vh#v':V l @ t '65'p ytPx2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666_HmH nH sH tH H`H Normal CJOJQJ_HaJmH sH tH DA`D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List jj !t Table Grid7:V0HH P Balloon TextCJOJQJ^JaJ6U`6 x_ Hyperlink >*B*phRv!R 0Unresolved MentionB*ph`^\q PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V (BO)MBT.$@0H!A>풠Uc-zD[&!rX=}zC0` ި%.]Ssd--7 +fOZեrŵVœ\lji2ZGwm-3˵j7\ Uk5FҨ-:xRkcr3Ϣ+9kji9OP Et-j|#p;E=Ɖ5Z2sgF=8 K}*7c<`*HJTcB<{Jc]\ Ҡk=ti"MGfIw&9ql> $>HmPd{(6%z:"'/f7w0qBcF6f Iöi1(\}B5ҹ~Bcr6I;}mY/lIz1!) ac 1fm ƪN^I77yrJ'd$s<{uC>== Ƌ(uX=WA NC2>GK<(C,ݖm: &-8j^N܀ݑ$4:/x vTu>*ٞn{M.Ǿ0v4<1>&ⶏVn.B>1CḑOk!#;Ҍ}$pQ˙y')fY?u \$/1d8*ZI$G#d\,{uk<$:lWV j^ZơSc*+ESa1똀 k3Ģxzjv3,jZU3@jWu;z \v5i?{8&==ϘNX1?  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