MEDICAL STUDENT
STUDENT CLERKSHIP APPLICATION
Full Name:
_________________________________________________________
(Last Name)
(First Name)
(MI)
Address:
_________________________________________________________
City:
__________________________________________State:__________________Zip:__________
E-Mail:
___________________________________________Phone:_____________________________
DOB:
__________
SSN (last 4 digits only; required for EMR access): __ __ __ __
EDUCATION
Pre Medical Education: College or University:______________________________________________________
Degree:________________________________
Medical Education:
Date Graduated:_________________________
School:__________________________________________________________________
Expected Date of Graduation:_____________________
Please use a separate form for each clerkship to which you are applying.
Generally only 3 Aurora rotations will be allowed per student.
Please note supplemental application materials required for Sub-Internship rotations
Applying for Clerkship in the field of:_____________________________________________________________
Aurora Site:___________________________________________________________________________
(Leave blank if unknown; Aurora Sinai; Aurora St. Luke’s; West Allis Memorial; Aurora Psych, Other)
Sponsoring Physician (if known):________________________________________________________________
Start/End Dates (TOP 3 CHOICES):
1. ______________________________________
2. ______________________________________
3. ______________________________________
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How did you hear about this opportunity?
How will this rotation contribute to your future training and career plans?
Proof of Medical School liability coverage and Letter of Good Standing from the Dean’s
Office must accompany this application.
Will you require housing for this rotation?
NO_____
YES_____ Limited housing is available for visiting
students; students will be asked to contribute ~$400 toward costs. A fee waiver application is available upon
request.
Please return this form to:
Susan Bayens
Coordinator, Visiting Medical Students
Department of Medical Education
Aurora Sinai Medical Center
1020 North 12th Street; OHC 3073
Milwaukee, WI 53233
E-Mail: sue.bayens@aurora.org
Phone: 414-219-5004
Fax: 414-219-4119
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Supplemental Applications Materials
For Rotations in Internal Medicine, Family Medicine, OB-GYN and Radiology
USMLE 1 Score _________________ or COMLEX 1 Score _________________
Number of attempts to pass _________
Significant experiences in the medical/healthcare field:
____________________________________________________________________________________
____________________________________________________________________________________
Significant life or career experiences outside of the medical/health field:
____________________________________________________________________________________
____________________________________________________________________________________
Why are you interested in a clinical rotation within the Aurora Health Care Residency?
____________________________________________________________________________________
____________________________________________________________________________________
Do you know anyone in or familiar with our Hospital System or Program? If yes, please explain:
____________________________________________________________________________________
____________________________________________________________________________________
Do you have area contacts or “roots”, previous experiences or specific reasons why the Milwaukee
area is of interest to you?
____________________________________________________________________________________
____________________________________________________________________________________
What are your Residency and career goals as of now? Will you be considering our Program as a
potential training location to meet these goals?
____________________________________________________________________________________
____________________________________________________________________________________
3
Additional Items for Internal Medicine Sub-I ONLY
We most commonly provide students doing an “audition rotation” with a month of team-based ward
medicine, as we feel this is the best way to meet our Faculty and Residents and to get to know our
Program. Is this what would interest you?
_________________________________________________________________________________
As we have an increased number of students requesting these rotations, we may not be able to place
everyone on a team-based ward medicine teaching service. Would you be willing or interested in
doing a different rotation if we cannot place you on a ward team? If so, what would interest you
most? (Options may include a team-based medical intensive care unit and a team-based cardiology
care unit experience and possibly a number of subspecialty rotations working in an apprenticeship
model):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
We utilize 2 hospitals for training, Aurora St. Luke’s Medical Center (ASLMC) on Milwaukee’s South side
and Aurora Sinai Medical Center (ASMC) located in downtown Milwaukee. Do you have a preference
regarding the site of your training?
_________________________________________________________________________________
We utilize a month-to-month schedule whereby our rotations begin on the first calendar day of the
month and end on the last day. Although this schedule works best for us, at times we can make
accommodations for students on different schedules. What rotation schedules are you on and/or
would you be able to align the rotations requested with our schedule? Explain:
____________________________________________________________________________________
____________________________________________________________________________________
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