GME Rotation Request Form

(For currently enrolled medical students only)

Complete the information below to initiate the process for applying for an observership or clerkship experience. We will respond within one business day.

Start Date: *

(mm/dd/yyyy)

End Date: *

(mm/dd/yyyy)

Start Date: *

(mm/dd/yyyy)

End Date: *

(mm/dd/yyyy)

Type of Rotation (only one permitted per applicant): *

Department/Specialty: *

Name (First/Last): *

Mailing Address: *

Contact Phone: *

Email *

Year in medical school at time of requested rotation: *

Future Specialty Interest: *

Medical School Name: *

Medical School Mailing Address: *

Medical School's Authorized Signer Name (First/Last): *

Medical School's Authorized Signer Title: *

Medical School Coordinator Name: *

Medical School Coordinator Phone: *

Medical School Coordinator Email: *

Authentication *

* Required

GME Rotation Request Form

GME Rotation Request Form

Preferred Dates

Alternate Dates

Your Contact Information

Your medical school will be required to sign a short affiliation agreement with Virginia Mason. Please provide full name and title of medical school's authorized signer.

Clerkship Information