<p> The Children’s Hospital of Philadelphia 34th Street and Civic Center Boulevard, Philadelphia, PA 19104-4399 Founded 1855</p><p>Visiting Clerkship for Underrepresented Minority Medical Students</p><p>Section 1: Student Data</p><p>Name: ______Gender (circle): F M Last First M.I.</p><p>Address: ______Street City/State/Zip code</p><p>Phone: ( _ _ _ ) _ _ _ - _ _ _ _ Email: ______DOB: ______</p><p>Race/Ethnicity: African American Mexican American Mainland Puerto Rican Native American (American Indians, Native Hawaiians, Alaskan Natives) Other ______</p><p>USMLE Step 1 score ______USMLE Step 2 CK score (if available) ______</p><p>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 </p><p>Please rank your rotation preferences from 1 to 4, with 1 denoting your highest preference and 3 denoting your lowest preference: </p><p>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 _____</p><p>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.</p><p>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) ______</p><p>CHOP Subinternship</p><p>Inpatient Pediatrics Floor (general pediatrics plus a subspecialty - hematology, neurology, pulmology, renal, adolescent). Please list 2 in order of preference: 1) ______2) ______</p><p>CHOP Pediatric Emergency Department: ______University of Pennsylvania (HUP) NICU: ______</p><p>Section 3: Supplementary Application Checklist In addition to completing this application form, please submit the following items:</p><p>Personal statement discussing career goals One letter of recommendation (preferably from a pediatric attending) Curriculum vitae Official medical school transcript Photograph</p><p>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</p><p>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/</p><p>3</p>