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Green Bay Clinical Apprenticeship Sign Up Form

Thank you for your interest in the Clinical Apprenticeship and Preceptor program in the Discovery Curriculum at the Medical College of Wisconsin in Green Bay.  Please complete this form to add your name to our database for future student assignments.  Any questions about the program, contact Sunny Debelak at sdebelak@mcw.edu or (920) 403-4502

Physician Information

First Name  
Last Name  
Title  
Employer  
Specialty  

Contact Information

Physician Email  
Physician Phone  
Physician Pager  
Assistant Name  
Assistant Email  
Assistant Phone  

Facility Information

Hospital or Clinic Address (where student would report)  
City  

Availability

In order to participate in the Early Clinical Experiences Clinical Apprenticeship program, physicians would be required to host a student in four hour time slots.

August through December 2015
shadow
January through May 2016
Monday morning Monday afternoon
Tuesday afternoon Tuesday afternoon
Wednesday morning  
  Thursday morning
Friday afternoon Friday afternoon
Let us know if you have question or have any additional information to include.  

 

Page Updated 06/23/2016