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 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 * Queen's University Current Status * - Select -3rd year4th year Status at time of rotation * - Select -3rd year4th year Placement Information Rotation Information * - Select -Core Family PracticePediatricsPsychiatry Rotation dates from * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20152016201720182019 Rotation dates to * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20152016201720182019 Length of rotation (No of weeks) * - Select -13 weeks14 weeks15 weeks16 weeks17 weeks18 weeks Assigned Community Please choose Brockville, Prescott/Brockville, Perth, Picton. Special interests Family PracticeAnaesthesiaEROBS/gynGeneral Surgery 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.