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Application for Student Electives

 

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Application for Student Electives

Please complete the form below and select the ‘submit’ button at the bottom of the page to register online.

Please note the following items:

  • Letter from Dean’s Office confirming student status and malpractice insurance, personal medical insurance

  • Proof of immunization status

  • Recent photo
Must be sent to:
Summa Western Reserve Hospital
OU-COM Core Office
Attn:  Linda Ackerman
1900 23rd Street
Cuyahoga Falls, OH  44223

Questions? Call (330) 971-7225 or email Linda Ackerman.


Personal Information
*First Name
*Last Name
*Address 1
Address 2
*City
*State
*Zip
*Phone Number
*Email Address

Parental Information
Parents' Address 1
Parents' Address 2
City
State
Zip
Phone Number

Medical School Information
Medical School
Other (school not on list)
*City
*State
*Date of Graduation

Elective Information
*Preferred Elective #1
*Start Date
*End Date
Preferred Elective #2
Start Date
End Date
Preferred Elective #3
Start Date
End Date
Preferred Elective #4
Start Date
End Date
Is housing required this period? Yes No

  

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