2013-2014 CHOP Minority Clerkship Application

The Children’s Hospital of Philadelphia 34th Street and Civic Center Boulevard, Philadelphia, PA 19104-4399 Founded 1855

Visiting Clerkship for Underrepresented Minority Medical Students

Section 1: Student Data

Name: ______Gender (circle): F M Last First M.I.

Address: ______Street City/State/Zip code

Phone: ( _ _ _ ) _ _ _ - _ _ _ _ Email: ______DOB: ______

Race/Ethnicity: African American Mexican American Mainland Puerto Rican Native American (American Indians, Native Hawaiians, Alaskan Natives) Other ______

USMLE Step 1 score ______USMLE Step 2 CK score (if available) ______

Section 2: Rotation Requests The funded visiting clerkship will be available from July through November 2013. Start and end dates include the following: • August 4, 2014 to August 29, 2014 • September 2, 2014 to September 26, 2014 • September 29, 2014 to October 24, 2014 • October 27, 2014 to November 21, 2014

Please rank your rotation preferences from 1 to 4, with 1 denoting your highest preference and 3 denoting your lowest preference:

Rotation Dates: Rotation A: August 4, 2014 to August 29, 2014 _____ Rotation B: September 2, 2014 to September 26, 2014 _____ Rotation C: September 29, 2014 to October 24, 2014 _____ Rotation D: October 27, 2014 to November 21, 2014 _____

1 Type of Rotation: You can choose to rotate for the month as a sub-intern or in an elective rotation. The sub-intern rotations take place on an inpatient floor, the Emergency Department or in the NICU.

CHOP Elective (cardiology, endocrinology, gastroenterology, hematology, oncology, renal, infectious disease, and more that you can find listed in the Perelman School of Medicine Catalog for). Please list 3 in order of preference: 1) ______2) ______3) ______

CHOP Subinternship

Inpatient Pediatrics Floor (general pediatrics plus a subspecialty - hematology, neurology, pulmology, renal, adolescent). Please list 2 in order of preference: 1) ______2) ______

CHOP Pediatric Emergency Department: ______University of Pennsylvania (HUP) NICU: ______

Section 3: Supplementary Application Checklist In addition to completing this application form, please submit the following items:

Personal statement discussing career goals One letter of recommendation (preferably from a pediatric attending) Curriculum vitae Official medical school transcript Photograph

The application deadline for the Visiting Clerkship for Underrepresented Minority Medical Students is May 5, 2014. Please send your application materials to: CHOP Minority Recruiting Committee (MRC) Attn: Jessica Fowler, MD MPH CHOP Pediatric Residency Program 34th Street and Civic Center Blvd. Room 9NW55 Philadelphia, PA 19104

2 Section 4: Visiting Student Application Upon receiving official notification from the Multicultural Physicians’ Alliance of your acceptance into our visiting clerkship program, please immediately complete and submit a visiting student clinical elective application to the Perelman School of Medicine at the University of Pennsylvania. The website address is: http://www.med.upenn.edu/visitingstudents/