The Hospital of the University of Pennsylvania
Division of Plastic Surgery
Funded 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: ( _ _ _ ) _ _ _ - _ _ _ _
Race/Ethnicity: 




Email: __________________________ DOB: _____________
African American
Latino American
Mainland Puerto Rican
Native American (American Indian, Native Hawaiian, Alaskan Native)
Other _________________
USMLE Step 1 score _________
USMLE Step 2 CK score (if available) ________
Section 2: Rotation Requests
The funded visiting clerkship will be available from August through October 2015. Start and
end dates include the following:
•
August 3, 2015 to August 28, 2015
•
August 31, 2015 to September 25, 2015
•
September 28, 2015 to October 23, 2015
•
October 26, 2015 to November 20, 2015
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 3, 2015 to August 28, 2015
Rotation B: August 31, 2015 to September 25, 2015
Rotation C: September 28, 2015 to October 23, 2015
Rotation D: October 26, 2015 to November 20, 2015
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_____
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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 surgical attending)
 Curriculum vitae
 Official medical school transcript
 Photograph
The application deadline for the Visiting Clerkship for Underrepresented Minority Medical
Students is May 31st, 2015.
Please send your application materials to:
Division of Plastic Surgery
Kris Gallagher
Attn: Visiting URM Clerkship Program
7th Floor South Pavilion
3400 Civic Center Blvd
Philadelphia, PA 19104
Section 4: Visiting Student Application
Upon receiving official notification 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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