Mountain Area Health Education Center
501 Biltmore Ave, Asheville, NC 28801 ~ (828) 257-4400
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Fourth Year Elective Form
Personal Information
Name:
Sex:
Male
Female
Phone No:
Best time to call:
Phone No:
Fax No:
Address
Email
School Information:
School:
Graduation Year:
Course Director:
Phone No:
Fax No:
Person verifying this student is in good standing with the University, has completed all pertinent OSHA training and is covered for liability during this community rotation:
If applying for elective:
Have you read the course descriptions of our electives?
Yes
No
Type of rotation preferred
A1 (Inpatient)
WA (Outpatient)
AAC (Outpatient)
HAC (Outpatient)
COPR (Outpatient)
PM/R (Outpatient)
If you have comments about your preferences, please include them here:
Are you interested in Asheville residency program?
Yes
No
Are you interested in Hendersonville residency program?
Yes
No
Will your school give you credit for the rotation without going through the registrar's office at Chapel Hill?
Yes
No
(If you don't know or are not sure, please check with your registrar's office.)
If applying for selective (UNC students only):
Have you read the site descriptions in the Chapel Hill course book?
Yes
No
Type of rotation you are interested in:
A1 (Inpatient)
ACS (Outpatient)
Family Medicine (Outpatient)
Pediatrics (Outpatient)
Obstetrics (Outpatient)
Internal Medicine (Outpatient)
Rotation dates for electives and selectives:
1st choice
2nd choice
3rd choice
Will you need housing:
Yes
No
Housing cost:
Out-of-state ranges from $250-330/month ($50 deposit)
Duke, ECU, UNC, WFU - free
Once accepted for a rotation, you will need to complete a housing application.
Practice preference:
What kind of practice are you looking for?
In Asheville
Group(>2)
Rural
Partners (2)
Very Rural
Solo
Male Preceptor
Female Preceptor