Clinical Internship Application

Clinical Internship Application
Burnett School of Biomedical Sciences
College of Medicine
Attach Picture
Name: ________________________________________________________________
PID: _____________________ Date of Birth: ___________________ Sex: ________
Phone: ________________________________ Email: ____________________________________________
Address: __________________________________________________________________________________
Emergency Contact: _________________________________ Phone: ________________________________
Major(s): ______________________________________ Overall GPA1: __________
1
UCF GPA1: __________
GPAs are listed on your Degree Audit next to #1/#4 in the University Credit Hour Requirements section
Credits at UCF2: __________
2
Total Credits: __________ Graduation Month/Year: _____________________
30 completed credits at UCF are required by the start date of the internship
Grade in3:
3
Human Anatomy (ZOO 3733C): _____________ Human Physiology (PCB 3703C): _____________
If currently enrolled, enter expected grade with an asterix. If future enrollment, enter semester you will be taking the class
I am applying for internships in (check one only)
Fall
Spring
Have you previously completed a BSBS Clinical Internship?
Yes
No
Which? __________________
Have you previously interviewed for the Surgical Internship?
Yes
No
Would you participate in an internship that uses
Note other languages you are fluent in: _________________ this language to see patients?
Yes
No
Prior to selecting internships, please see the “Description and Selection Criteria” document for specific
information about each program, program requirements (such as minimum GPA, weekly hours required,
expenses, and other expectations), and selection criteria.
Please rank the internships for which you would like to be considered, using numbers such as “1” and “2”.
You will be reviewed primarily on your first choice, followed by your second choice. You will be considered for
third/fourth choice only if there are no competitive applicants for those positions. Only choose internships
that you wish to participate in if accepted. Please note, there are usually 110+ applicants for ~40 positions.
_______ Surgical Internship at Florida Hospital
> 3.5 UCF GPA?
Yes
No
> 3.3 UCF GPA?
Yes
No
> 3.3 UCF GPA?
Yes
No
Yes
No
~3 positions, interview required late Aug. or early Dec.
Minimum of 4-6 hours/week, flexible schedule, commuting, Florida Hospital expenses
_______ Private Practice Clinical Internship
~15-20 positions, 4 hours/week, commuting
_______ Osteopathic Family Practice Clinical Internship
~4 positions, 4 hours/week MTRF PM, commuting, Florida Hospital expenses
_______ Clinical Research Internship at Florida Hospital
~14 positions. Apply in Fall only for the entire Fall/Spring course
4-8 hours/week, commuting, Florida Hospital expenses
> 3.5 UCF GPA?
QBM Grade: _____
Application Status: Mark all the professional schools to which you may apply to or pursue:
Medical (Allopathic)
Nursing
Dentistry
PT/OT
Medical (Osteopathic)
Nurse Practitioner
Optometry
Podiatry
Physician Assistant
Chiropractic
Pharmacy
Public Health
Graduate
Veterinary
Other (list):
Would you be willing to shadow a Physician Assistant for part of the internship?
Have you taken the MCAT? _________
Yes
No
If accepted, what year would you begin Medical School? __________
Have you applied to Medical School? _________ If yes, what is the status (accepted, pending)? ____________
If no, when will you be applying4? _____________________
4
typically the summer after your Junior year
What medical specialties are you interested in pursuing? ___________________________________________
List other professional school applications and status: ______________________________________________
Experience: Please accurately list and briefly describe all prior and current internship, shadowing, research,
and health care delivery experiences, including total hours for each:
Statement of Purpose: Briefly describe why would you like to complete a clinical internship in medicine:
Availability: Internships have specific time requirements. Surgical requires morning availability, but times
may vary weekly depending on the assigned doctor, other days and times may work. Osteopathic requires
one 4 hour block weekly, on MTRF afternoons. Private Practice prefers one 4 hour block but two 2 hour
blocks weekly is an option. Clinical Research has specific time requirements in fall (~8-10:30) but is more
flexible in spring. You can mark days that currently conflict with your schedule if you are willing to move or
drop the class if accepted. Please consider commuting times to and from the location:
Can you rearrange your schedule to accommodate shadowing if necessary?
Yes
No
Note () your approximate availability for the internships to which you are applying. All internships
require a commute, therefore having a class immediately before/after a time slot may not work:
Surgical, Private Practice, Osteopathic (Please see Description and Selection Criteria document):
Monday
Tuesday
Wednesday
Thursday
Friday
AM (8-12 or 9-1)
Mid-Day (10-2 or 11-3)
PM (12-4 or 1-5)
Clinical Research Internship: Fall:
Spring:
Tuesday ~8:00-10:30 AM
6-8 hours/week of availability for research
Commuting: Can you commute?
Yes
No
Note () locations to which you can commute for the internships to which you are applying.
Willingness to commute further distances can make you a stronger applicant for certain internships:
Surgical:
Downtown Orlando
Clinical Research Internship:
Florida Hospital (Downtown Orlando)
Osteopathic Family Practice:
Florida Hospital East
Private Practice:
UCF Area, Oviedo, Waterford
Downtown Orlando, Winter Park
North:
Altamonte
Lake Mary
Sanford
Deland/Orange City
South:
Lake Nona
Kissimmee
West:
Apopka/Ocoee
Grades: Attach a list of your grades. The “course summary” view that lists all courses and grades neatly is
preferred. An unofficial transcript is acceptable. Degree audits are difficult to read and not preferred.
Highlight major and science courses. Note expected grades of courses in which you are currently enrolled.
Involvement: Attach a CV, resume, or list of involvement including experiences, shadowing, research, clubs,
leadership positions, etc., including locations and total hours for each when relevant.
Schedule: Attach your course schedule (“weekly view”) for the semester to which you are applying. Note any
classes that are flexible in the event that you are selected for an internship.
Please contact Dr. Robert Borgon (Robert.Borgon@ucf.edu) or Dr. Genaro Lopez (Genaro.Lopez@ucf.edu) for
application or program questions.
Submit or mail your application to 4364 Scorpius St., HPA2 Room 335, Orlando, FL 32816-2360