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Elective / Rotation Information

Enter your information in the form below:


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My Elective / Rotation has been set up through *:

ROMP SWOMEN NOSM U of T

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Personal Information:

Gender:*

Female Male

Last name:*

First name:*

Email Address:*

Phone Number:*

Elective / Rotation Details:

GBHS Community:*

GBHS Preceptor:*

Rotation / Elective Discipline: *

Rotation Dates:*

Accomodation Required:* Yes No

Current Medical University:*

International Student / Resident:* Yes No

Level of Training:*

Medical Observer

Pre-Clerkship

Clinical Clerkship: Yr 1. Yr. 2 Yr. 3 Yr. 4

Post Graduate: Yr 1. Yr. 2 Yr. 3 Yr. 4 Yr. 5

Discipline / Specialty:*

Student Number:*

CPSO Number:*

My Elective / Rotation is:*

Funded Unfunded




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