Medical Student Rotation Placement Request Form

Thank you for your interest in completing a rotation with Parkview Health. We will do our best to honor your request, but we do not guarantee placement. This form must be filled out completely and submitted with a copy of your transcripts. We will review your request after we receive your complete Request Form, unofficial medical school transcript, and USMLE/COMLEX transcript.
Full name (including middle initial)  *Date of birth  *Medical school name  *Graduation date  *Phone number  *School email (.edu address only)  *Any academic warnings or remediation? If yes, please explain. Any gaps or interruptions in your medical training? If yes, please list. Please upload a copy of your unofficial medical school transcript  *Any disciplinary warnings or remediation? If yes, please explain. USMLE/COMLEX Step 1 Score  *USMLE/COMLEX Step 2 Score  *Number of attempts, USMLE/COMLEX Step 1 Number of attempts, USMLE/COMLEX Step 2 Please upload a copy of your USMLE or COMLEX scores  *Were you raised or trained in the Fort Wayne region? 
Do you plan on staying in the Fort Wayne region when you finish your medical training? 
Specialty after graduation? Will you be applying to any of the Parkview Health residency programs? 
Do you have relatives who work within Parkview Health? If so, where and in what capacity?  *
School name Does your school have an affiliation agreement with Parkview Health?  *
School program coordinator name School program coordinator email Rotation start date Rotation end date Desired specialty for requested rotation Name of desired provider Personal statement on why you have chosen to pursue the field of medicine (100 words or less).  *Required for 4th year medical students requesting an OB/GYN rotation: Please prepare a brief statement regarding your background that led you to an interest in OB/GYN or women's healthcare and how you feel a rotation at Parkview Health will assist you in reaching your educational goals?  *