Residents and Medical Students

To apply for an elective, please fill out the following form:

Please note that we can only take one learner (resident or student) at any given time so elective spots fill up quickly.  To avoid disappointment , please try to apply for the elective well ahead of time.  At present we would appreciate that the request be made at least 3 months prior. If there are questions, please do not hesitate to contact Dr Karen Busche at karen.busche@medportal.ca
Please note we are unable to accommodate learners during July and August.

After you have filled out the elective form, you will hear from our office about whether any of the times requested are available or not and once confirmed, a clinic schedule will be planned for your elective.

Your Name *

Your Email *

What university do you currently attend? * McMasterOther:

What type of elective are you applying for? *

Please select your current educational status. *

Please provide, in order of preference, 3 timespans you would prefer for your elective *

Ie. 1st Choice - January 6, 2014 to January 20, 2014; 2nd Choice - March 2, 2014 to March, 2014 etc. ***Please note that for medical students and residents we accommodate block electives for a maximum of two weeks and horizontal electives for a minimum of 4 weeks and maximum of 6 weeks.
1st choice: Beginning --- Ending

2nd choice: Beginning --- Ending

3rd choice: Beginning --- Ending

If you would like to do a horizontal elective, please indicate your availability (select all that apply).

What will your educational level be at the time that you indicated as your first choice for your elective? *Pre Clerk (1st year medical student - any time prior to starting your formal clerkship)Clerk (2nd year medical student - from start of clerkship until June of your second year)Clerk (3rd year medical student)PGY1 Family Medicine ResidentPGY2 Family Medicine ResidentIMG ObserverOther:

Why do you want to do an elective with SHN? *

What are your learning objectives from this elective? *

If you are an IMG, have you passed your MCCEE? (Please note that you will be requested to submit proof of passing MCCEE) YesNoN/A

Do you have any other comments you would like to make regarding your request?

if you are a resident, please indicate when your half day backs are.

If you are a medical student and have a PPI scheduled during the elective, please indicate when it is.