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Application For Undergraduate Medical Education Clinical Courses Eligibility: Senior Elective courses are open to fourth year medical students in accredited U.S. medical schools. Instructions: Please complete this application on-line, print the resulting page and send by mail, a supporting letter from your Dean. The Dean's letter should indicate that liability and health insurance will be in force during the course of your clinical education at Winthrop-University Hospital. Send letter to: Winthrop-University Hospital Office of Academic Affairs 222 Station Plaza North, Suite 510 Mineola, NY 11501. Items marked with an asterisk (*) must be completed. Name in full: * First Name Middle Name * Last Name Maiden Name * E-mail Address * Address * City * State * Zip * Phone * Citizenship US Native Born citizen Naturalized US citizen Canadian citizen * Medical School: Program Request Inclusive dates of desired training: * From * To Clinical Experience Requested (Click on course name to review course description. Please indicate number of weeks in each): Course # Course Name Weeks AMCAR 701 Emergency Medicine AMCAR 702 Toxicology INMED 701 Cardiology INMED 702 Endocrinology and Metabolism INMED 703 Gastroenterology, Hepatology and Nutrition INMED 704 Gastroenterology Research INMED 705 Geriatrics INMED 706 Hematology INMED 707 Infectious Disease INMED 708 Infectious Disease Research INMED 709 Medical Oncology INMED 710 Oncology Research INMED 711 Medical Research INMED 712 Nephrology INMED 713 Neurology INMED 714 Pulmonary and Critical Care Medicine INMED 715 Rheumatology and Immunology INMED 716 Subinternship in Critical Care Medicine INMED 717 Subinternship/Elective in Medicine INMED 718 Allergy OBGYN 701 Maternal-Fetal Medicine OBGYN 702 Subinternship OBGYN 703 Reproductive Endocrinology OBGYN 704 Gynecology/Oncology PATH 701 Clinical Pathology PATH 702 Diagnostic Anatomic Pathology PEDS 701 Ambulatory Pediatrics PEDS 702 Neonatal Intensive Care PEDS 703 Pediatric Infectious Diseases PEDS 704 Pediatric Subinternship PEDS 705 Pediatric Subspecialties RAD 701 Radiology SURG 701 Plastic and Reconstructive Surgery SURG 702 Surgical ICU TCV 701 Cardiac Surgery TCV 702 Thoracic/Vascular Surgery UROL 701 Urology

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