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Medical Student Elective Internal Medicine Dept Form

Contact Information

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(12345)
(123-123-1234)
(123-123-1234)

(123-123-1234)

Emergency Contact

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(12345)
(123-123-1234)
(123-123-1234)

Rotation Information

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(mm/dd/yyyy)
(mm/dd/yyyy)


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(mm/dd/yyyy)



Other Information

Notice of Non-Discrimination Policy

The St. Luke's Department of Internal Medicine complies with applicable federal, state and local laws, regulations and ordinances governing equal opportunity and non-discrimination, including without limitation, Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, as amended, Section 504 of the Rehabilitation Act of 1973, as amended, and the Age Discrimination Act of 1975. The Department of Internal Medicine provides equal educational opportunity to qualified applicants and students and does not discriminate on the basis of age, sex, ancestry, race, color, national origin, religion or disability in recruitment or admission, educational programs and policies, housing, scholarships and loan programs, or non-academic services such as recreation, counseling or social activities. The Director of Medical Education and the Chairman of Medicine in conjunction with the vice president of Medical Affairs are responsible for the implementation, coordination, and confirmation of equal opportunity throughout the Department of Internal Medicine.

Applicant acknowledgment

The signature of the applicant and accompanying submission of an application to the Medical Affairs Department or the Department of Medical Education in St. Luke's Department of Internal Medicine constitutes acknowledgment of this policy.