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  1. Application Form for Participation in WAFP’s Summer Externship Program

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  3. School
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  4. (*)
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  6. School Address

    Your address while you are attending school.
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  11. Permanent Address

    Your address while you are NOT attending school.
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  16. Emergency Contact

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  2. Please list all places where you have lived for three or more years.

  3. First Location

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  7. Second Location

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  11. Third Location

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  15. Fourth Location

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  19. Please name a family physician you know from your past experiences or from medical school.
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  1. Stipulations

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    Please check the box to confirm that you have read and understand this stipulation.
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    Please check the box to confirm that you have read and understand this stipulation.
  4. (*)
    Please check the box to confirm that you have read and understand this stipulation.
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  1. Essay Criteria

    As part of the application process, please respond to all five of the following questions on the last page below. Your response to all of the questions is limited to one single spaced typewritten page that includes your name. Essays will be read not only for content, but also for proper grammar, punctuation, cohesiveness and writing style. The following should be included:
    1. Please describe your interest in Family Medicine and why you would like to participate in the family medicine externship program?
    2. What Family Medicine activities have you participated in?
    3. What specific medical activities, procedures and ancillary activities (community interactions, nursing home visits, etc.) of a family physician do you hope to participate in or observe during the externship?
    4. What do you hope to get out of this experience for your personal and professional development?
    5. Is there any additional information about you that you would like us to know?
  2. Submit your Essay as an attachment

  3. Submit your Essay as an attachment
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  4. Copy and Paste your Essay

    Note: Formatting may be lost in this process.
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Wisconsin Academy of Family Physicians - Foundation  |  210 Green Bay Road  |  Thiensville, WI 53092
Phone: (262) 512-0606  |  Fax: (262) 242-1862
 
WAFP-F is a 501(c)3 non-profit organization. Your donation is tax deductible to the extent allowed by law.
No goods or services are provided in exchange for your financial donation.

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