Adolescent Medicine Section/Division of General Pediatrics
University of Washington
Seattle, Washington
Application for Adolescent Medicine Fellowship Training
Today’s date: __________
Date fellowship to begin: __________
Name: ______________________________________________________
Address: _____________________________________________________
_____________________________________________________________
Phone: ______________________________________
Fax: ________________________________________
Email: ______________________________________
Social Security #:
_
Citizenship: ___________________
Undergraduate education
College / University
Location
From
To
Degree
__________________________________________________________________________________________
Graduate/Professional education
University
Location
From
To
Degree
__________________________________________________________________________________________
__________________________________________________________________________________________
Internship& Residency
Institution
Location
Type of Training
Dates
# Months
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Fellowships, pre/post doctoral training
Institution
Location
Type of Training
Dates
# Months
Other pertinent work or learning experience
Pertinent research experience
__________________________________________________________________________________________
Membership in Professional Societies:
__________________________________________________________________________________________
Honors, Scholarships, Grants, etc.:
__________________________________________________________________________________________
Publications:
__________________________________________________________________________________________
__________________________________________________________________________________________
Are you board-certified? ___________________
Date: _________________
(specialty)
Are you licensed to practice medicine?
State: ___________________
Please request three professional references
Name
Title
Address
1. _______________________________________________________________________________________
_______________________________________________________________________________________
2. _______________________________________________________________________________________
_______________________________________________________________________________________
3. _______________________________________________________________________________________
_______________________________________________________________________________________
Please attach a personal statement briefly describing your background, particular interests in adolescent
medicine, STD/HIV research goals and career path contemplated.
Please send completed application to:
Phone: (206) 987-2028
Fax (206) 987-3959
Email: lpr@u.washington.edu
Laura P. Richardson, MD
Fellowship Director
Adolescent Medicine Section
UW Division of General Pediatrics
Children’s Hospital & Regional Medical Center
4800 Sand Point Way NE, M2-4
Seattle, WA 98105