All post-grad rotations must be a minimum of 4 weeks to be accepted and funded by ERMEP. Personal Information Last Name * First Name * Preferred First Name E-mail Address * (Please use your University e-mail address) Phone # * Please use the format (xxx) xxx-xxxx Cell/Mobile # Please use the format (xxx) xxx-xxxx Gender * - Select -MaleFemale Information is required for accommodation purposes. Stream * - Select -AnglophoneFrancophone CPSO Number * Current Address Street * City * Province/Territory * - Select -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code * Please use the format xxx xxx Is your current address the same as your permanent address? * - Select -YesNo Permanent Address Street City Province/Territory - None -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Please use the format xxx xxx School Information Medical School * - Select -University of OttawaQueen's UniversityUniversity of Western OntarioMcMaster UniversityUniversity of TorontoNorthern Ontario School of Medicine Please indicate your discipline * - Select -Family MedicineEmergency MedicineInternal MedicineSurgeryObstetricsAnaesthesiaOther (please indicate below) If other discipline (Please indicate) Current Status * - Select -PGY 1PGY 2PGY 3PGY 4PGY 5 Status at time of rotation * - Select -PGY 1PGY 2PGY 3PGY 4PGY 5 Name of Program Director * Program Director's email address * Placement Information Rotation Information * - Select -Family Practice ElectiveFamily Practice CoreSpecialty ElectiveSpecialty Core Rotation dates from * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 Rotation dates to * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 Length of rotation (No of weeks) * - Select -4 weeks5 weeks6 weeks7 weeks8 weeks Preferred Communities Please choose up to three locations Preferred preceptor Special interests Family PracticeAnaesthesiaEROBS/gynGeneral SurgeryInternal Medicine Please choose your special interests, if any. Do you give ERMEP permission to choose a location if your choices are not available * - Select -yesno Do you have a vehicle? * - Select -yesno Will you require accomodations? * - Select -yesno Do you have any pet allergies? (Please state) Does ERMEP have your permission to use your photograph in published articles, website, newsletters, flyers, posters, brochures and presentation materials? * - Select -yesno Expectations of learning experience Comments Hobbies and/or Interests Cancellation PolicyThe Eastern Regional Medical Education Program [ERMEP] along with the Distributed Medical Education [DME] considers it unprofessional to cancel a rotation once a preceptor is confirmed. ERMEP considers it a breach of professionalism when the learner cancels without a valid reason less than four weeks from the start date of the rotation. ERMEP will then report this to the schools and ask that they deal with this as unprofessional behavior. It is important to recognize that preceptors are often very annoyed by late changes due to their scheduling requirements. Accommodation cancellations must be made through ERMEP a minimum of four weeks prior to placement start date. By submitting this application, I agree to abide by all of ERMEP policies and confirm that I have not applied to any other Networks. I understand that once the Eastern Regional Medical Education Program has contacted me with the name of a preceptor, it is unprofessional for me to cancel the rotation. I acknowledge that ERMEP will notify my school of any unprofessional behaviour. Cancellation Policy Agreement * I agree to the Cancellation Policy What code is in the image? * Enter the characters shown in the image.