Non LCME Visiting Student Applications

 The George Washington University SMHS

Application Form    (  Asterisked information is required to complete application  )

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Student Information:
*First Name:
*Last Name:
*Gender:
Female
Male
*Date of Birth:
/ /
*U.S. Citizenship:
Yes
No
*Street Address 1:
   Street Address 2:
*City: *State: *Zip:
*Phone:
*Email Address:
*Graduation Date:
/ /
*Have you attended classes or worked at GWU in the past?
No
Yes (Please, explain)

Medical School's Information:
*Location of Medical School:
*Name of School:
*School Street Address 1:
   School Street Address 2:
*City: *State: *Zip:

Health Insurance Information:
*I am covered by personal Health Insurance:
Yes
No
*Please list company:
*Please list your policy number:

Student Affairs Dean / Registrar's Office Information:
Please Note: We will be requesting verification of your application througth your dean or registrar's email address.   Please, make sure that this information is accurate.
*First Name:
*Last Name:
*Title:
*Phone Number:
*Fax Number:
*Email Address:

Elective Requests:
Please Note:
Refer to The Senior Course Catalog to select courses for visiting rotations. Indicate preferences by department and course number (i.e., med352; pchi382). The start dates are indicated in bold on the academic year calendar. Please use our academic calendar for scheduling dates. The dates of the rotation are fixed and your dates must correspond to the week blocks.
Elective Dept/Course # 1st Choice Start Week 2nd Choice Start Week 3rd Choice Start Week
*1 * *        
   2                
   3                

Basic Science Grades:
Please Note: You must fill in a minimum of ten courses in this section.
Gross Anatomy
Microscopic Anatomy
Neurobiology
Biochemistry
Immunology
Physiology
Microbiology
Pathology
Introduction to Clinical Medicine
Pharmacology
Other 1:
Other 2:
Other 3:
Other 4:
Other 5:
Other 6:
Other 7:
Other 8:
Other 9:
Other 10:

Third Year Clerkship Grades:
*Medicine
*Surgery
*Ob/Gyn
*Pediatrics
*Psychiatry
Other:

Conditioned / Failed a Course:
*Have you ever conditioned or failed a course?
Yes
No
If yes, please explain:

Other:
*MD - USMLE Step 1 Score:
*DO - COMLEX Score:
*Did you pass on your first attempt?
Yes
No
Please type / copy and paste your letter of interest below:
Please type / copy and paste your curriculum vitae below:

Note: 
There is a $75 application fee.  If you are accepted into the course, payment will be required to complete the application process and officially register you for the course.
Make your check payable to The George Washington University (GWU).

    (Don't repeat submitting your application)

Questions or Comments? Please send email to gwumc-electives@gwumc.edu.