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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.  Please complete this form to add your name to our database for future student assignments.  Any questions about the program, contact Stephanie Shaw at sshaw@mcw.edu or (414) 955-8207.

 

Physician Information

First Name
Last Name
Title
Employer
Specialty
I am an existing faculty or volunteer faculty at MCW Yes  No  

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 for four hours on either Monday afternoon, Tuesday afternoon, Thursday morning or Friday afternoon.
Monday afternoon
Tuesday afternoon
Thursday morning
Friday afternoon
Let us know if you have question or have any additional information to include.

 

Page Updated 08/01/2016