Professional Documents
Culture Documents
Stlouis
Stlouis
Stlouis
Last 4 digits of SSN# XXX-XX-___________ Date of Birth: ___/____/_____ Gender: Male _____ Female ____ (Please mark one)
The above named student is in good academic standing at this school and has my approval to participate in the elective(s) listed above. Yes No
On the dates requested for participation, this student will be in his/her final year of medical school, and will have successfully completed all required junior level
clerkships. Yes No
This student will have personal health and hospitalization insurance in effect through his/her home school during the above mentioned dates. Yes No
This student has completed a criminal background check that did not disclose information with relevance to patient care responsibilities. Yes No
This student is covered by Liability, Malpractice while away from our school.
SLU requires minimal coverage limits of $2,000,000 (2 million). (Please enclose proof of insurance) Yes No
__________________________________________ __________________________________________________________
Signature of School Official Name of School Place School Seal
__________________________________________ __________________________________________________________ Here
Name and Title Mailing Address
__________________________________________ __________________________________________________________
Date City, State, Zip Code
(____) ________________________
Telephone Number
Section III: To be completed by the Office of Curricular Affairs
The student Ƒ is approved Ƒ is not approved for the elective indicated below.