Final Year Clinical Externship Program
Home Institution Approval Form
The University Veterinary Teaching Hospitals Sydney & Camden including AREPH
This form must be completed by the Office of Dean or Head of School and submitted with a completed Final Year Clinical Externship
Program & Unit of Study Enrolment Form. No application will be processed without confirmed approval from the home institution to
undertake the Final Year Clinical Externship Program.
1. APPLICANT DETAILS
First Name(s):
Surname/Family Name:
Name of current degree:
Degree was commenced on: MM / DD / YYYY Expected date of graduation: MM / DD / YYYY
2. HOME INSTITUTION DETAILS
Institution’s Name:
Suburb/town:
Postal code/Zip:
State:
Country:
Dean/Head of School’s Name:
Title:
First Name:
Institution is accredited with: VSAAC
AVMA
Surname/Family Name:
RCVS
EAEVE
Memorandums of Understanding are in place between the home institution and The University of Sydney?
An MOU is in place.
An Exchange Agreement is in place.
3. HOME INSTITUTION APPROVAL
I have granted approval for the above named student to undertake the Final Year Clinical Externship Program at
the nominated University Veterinary Teaching Hospital.
I confirm that the Applicant will be in their final year of the degree at the commencement of their placement and
will continue to be enrolled with our institution throughout the duration of the placement.
The Applicant is of good character and academic standing
We are willing to assist final year students from The University of Sydney, Faculty of Veterinary Science who may
seek to undertake placements at our institution in the future
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4. Insurance
The Applicant will be covered by the home institution’s insurance policies whilst on placement including:
Public Liability Insurance
Professional Indemnity Insurance including Veterinary Malpractice
Personal Accident/Health/Travel Insurance
Attached is a copy of certificates of currency for the above insurance policies
If no to any of these, please provide details as to how this type of insurance coverage will be provided.
OR
The Applicant will provide their own insurance coverage for:
Public Liability Insurance
Professional Indemnity Insurance including Veterinary Malpractice.
Personal Accident/Health/Travel Insurance
Attached is a copy of certificates of currency for the above insurance policies.
If no to any of these, please provide details as to how this type of insurance coverage will be provided.
OR
The Applicant will not be covered by Public Liability or Professional Indemnity insurance policies from the home
institution nor personally. The Applicant agrees to:
Sign a Volunteer Agreement Form from The University of Sydney
Acknowledge that this arrangement may restrict their learning experience during the placement
Provide evidence of their own Personal Accident/Health/Travel Insurance no later than 28 days prior to
commencement of their placement
Signature: _______________________________Date: MM / DD / YYYY Faculty/School Stamp: ___________________
Title:
Position:
First Name:
Phone:
Surname/Family Name:
Facsimile:
Email Address:
Unsigned and Stamped Home Institution Approval Forms will not be processed.
1 December 2010
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