UT Southwestern Emergency Medicine Visiting Elective Program Application

Registrant Info

1. Personal Information *This question is required.

First Name

Last Name

Primary Phone Number

Email Address *This question is required. This question requires a valid email address.

Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Birthplace

Citizenship *This question is required.

Current Address

Permanent Address

Race/Ethnicity

2. Educational Background *This question is required.

Medical School *This question is required.

Expected Graduation Date *This question is required. This question requires a valid date format of MM/DD/YYYY.

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3. How did you hear about the Visiting Elective Program? (check one)

Conference/Residency Fair: *This question is required.

Please enter an 'other' value for this selection.

4. Please submit a letter of Intent (1page maximum). In your letter of intent, please explain your path to medicine and your demonstrated interest in serving underserved communities. *This question is required.

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In addition to completing this application for the UTSW Visiting Elective Scholars Program you must also complete an application in VSLO for the Emergency Medicine Elective. The Scholars Program is for EMED 1901.

5. I certify that the information provided on this application is accurate. *This question is required.

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