TCWD Rural Rotation Incentive Program
Applications for this incentive program are open to 3rd/4th year medical school students or primary care residents planning to complete a rural rotation. If your rotation has already began before you apply, you are not eligible for this incentive as this is not a reimbursement program.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
LinkedIn Profile:
Optional
You are a...
*
Primary Care Resident (FM, IM, OBGYN, Peds, Psych)
Medical School Student (4th Year)
Medical School Student (3rd Year)
Current Medical School or Residency Program:
*
Please use full name of school or program
Anticipated Graduation
*
-
Month
-
Day
Year
Date
Program Coordinator's Name
*
First Name
Last Name
Program Coordinator's Email
*
example@example.com
Information about your scheduled rural rotation
Please note that rural rotations need to already be planned and approved by your program. You are not eligible for this incentive if you rotation has already began prior to applying for the program.
Practice Site Name
*
Practice Site Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Practice Site Contact Email:
*
example@example.com
Rotation Start Date
*
-
Month
-
Day
Year
Date
Rotation End Date
*
-
Month
-
Day
Year
Date
Clinical Rotation Type:
*
Family Medicine, Surgery, OBGYN, Peds, etc.
Are you taking any planned time off during this rotation (aka vacation time?)
*
YES
NO
Please upload a Letter of Support from your Program Director
*
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Letter needs to address your planned rural rotation, must be on official letterhead, and must be signed by the program director.
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Please upload your Personal Statement
*
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Personal Statements should state why you decided to complete a rural rotation, any previous experiences you have working with rural or underserved populations, and why you believe you are the best fit for this incentive award.
Cancel
of
Submit
Should be Empty: