The Children’s Hospital of Philadelphia
34th Street and Civic Center Boulevard, Philadelphia, PA 19104-4399
Founded 1855
Visiting Clerkship for
Underrepresented Minority Medical Students
Section 1: Student Data
Name: ___________________________________________________ Gender (circle): F
Last
First
M.I.
M
Address: ______________________________________________________________________
Street
City/State/Zip code
Phone: ( _ _ _ ) _ _ _ - _ _ _ _
Email: __________________________ DOB: _____________
Race/Ethnicity:  African American
 Mexican American
 Mainland Puerto Rican
 Native American (American Indians, Native Hawaiians, Alaskan Natives)
 Other _________________
USMLE Step 1 score _________
USMLE Step 2 CK score (if available) ________
Section 2: Rotation Requests
The funded visiting clerkship will be available from July through November 2013. Start and end
dates include the following:
•
August 4, 2014 to August 29, 2014
•
September 2, 2014 to September 26, 2014
•
September 29, 2014 to October 24, 2014
•
October 27, 2014 to November 21, 2014
Please rank your rotation preferences from 1 to 4, with 1 denoting your highest preference and 3
denoting your lowest preference:
Rotation Dates:
Rotation A: August 4, 2014 to August 29, 2014
Rotation B: September 2, 2014 to September 26, 2014
Rotation C: September 29, 2014 to October 24, 2014
Rotation D: October 27, 2014 to November 21, 2014
_____
_____
_____
_____
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Type of Rotation:
You can choose to rotate for the month as a sub-intern or in an elective rotation. The sub-intern
rotations take place on an inpatient floor, the Emergency Department or in the NICU.
CHOP Elective
(cardiology, endocrinology, gastroenterology, hematology, oncology, renal, infectious disease,
and more that you can find listed in the Perelman School of Medicine Catalog for).
Please list 3 in order of preference:
1) __________________________________________________
2) __________________________________________________
3) __________________________________________________
CHOP Subinternship
Inpatient Pediatrics Floor (general pediatrics plus a subspecialty - hematology, neurology,
pulmology, renal, adolescent). Please list 2 in order of preference:
1) __________________________________________________
2) __________________________________________________
CHOP Pediatric Emergency Department:
University of Pennsylvania (HUP) NICU:
__________________
__________________
Section 3: Supplementary Application Checklist
In addition to completing this application form, please submit the following items:
 Personal statement discussing career goals
 One letter of recommendation (preferably from a pediatric attending)
 Curriculum vitae
 Official medical school transcript
 Photograph
The application deadline for the Visiting Clerkship for Underrepresented Minority
Medical Students is May 5, 2014.
Please send your application materials to:
CHOP Minority Recruiting Committee (MRC)
Attn: Jessica Fowler, MD MPH
CHOP Pediatric Residency Program
34th Street and Civic Center Blvd. Room 9NW55
Philadelphia, PA 19104
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Section 4: Visiting Student Application
Upon receiving official notification from the Multicultural Physicians’ Alliance of your
acceptance into our visiting clerkship program, please immediately complete and submit a
visiting student clinical elective application to the Perelman School of Medicine at the University
of Pennsylvania. The website address is: http://www.med.upenn.edu/visitingstudents/
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