Rural Site Request Form Third Year Medical Students

RURAL SITE REQUEST FORM – THIRD YEAR MEDICAL STUDENTS

NAME: ID#: PHONE: UALBERTA EMAIL:

RURAL FAMILY MEDICINE DATES (DD / MMMM / YYYY ): START DATE TO END DATE

MY TOP SIX CHOICES FOR MY FIRST / ONLY FOUR (4) WEEK LOCATION ARE (SEE BELOW FOR POSSIBLE RURALCOMMUNITIES): **PLEASE NOTE THAT THIS REQUEST WILL ONLY BE CONSIDERED IF YOU HAVE EXTENUATING CIRCUMSTANCES FOR A CERTAIN COMMUNITY THAT YOU WOULD LIKE TO BE PLACED IN** 1. 2. 3. 4. 5. 6.

RURAL COMMUNITIES ARE: Athabasca Fort McMurray Ponoka Vermilion Banff Hinton Redwater Viking Barrhead Innisfail Rimbey Wabasca Bellevue Jasper Rocky Mountain House Westlock Bonnyville Killam Smoky Lake Wetaskiwin Canmore Lac La Biche Spirit River Whitecourt Drayton Valley Lamont St. Paul Edson Lethbridge Trochu Fairview Peace River Vegreville

ACCOMMODATION: Office of Rural & Regional Health will provide free accommodations during your rural rotation. Please note that the student will be held personally responsible for any damages caused to the premises after their move in. It is the student’s responsibility to leave the accommodations in the same condition as when they moved in. Extra cleaning fees will be the responsibility of the occupant. I allow the Office of Rural & Regional Health to release my e-mail address to the RPAP Accommodation Coordinator for the sole purpose of providing accurate and timely accommodation to me if required, in accordance with the FOIPP provisions. No Yes Initial here to confirm:

I have a family that will accompany me during my rotation: No Yes # of: Adults (include self) Children  age child #1 age child #2 age child #3

Accommodation: Please email the completed form to Ms. Rattan Dhillon at [email protected] or drop it off in-person at our office located within the Division of Community Engagement at 2-115 ECHA. Please note that this form is to be filled out by all students in Class of 2017 for the purpose of releasing your information to RPAP for accommodations. ACCOMMODATION: The personal information requested on this form is collected under the authority of Section 33 (c) of the Alberta Freedom of Information and Protection of Privacy Act for the purpose of administering the undergraduate Rural & Regional Rotations Program. Questions concerning the collection, use or disposal of this information should be directed to: The Office of Rural & Regional, 2-115 ECHA, Edmonton AB T6G 2C9, Phone: (780) 492-0678, Fax: (780) 248-1163.