Supplemental Vsas Application For 4th Year Clinical Elective By A Visiting Student (Page 2 of 4) in pdf

Page 2 of VSAS Supplemental upload

DREXEL UNIVERSITY COLLEGE OF MEDICINE

Division of Clinical Education, 2900 Queen Lane, Philadelphia, PA 19129-1096

Supplemental VSAS Application for 4

Year Clinical Elective by a Visiting Student

INSTRUCTIONS:

1. Complete this application. No modifications may be made.

2. Complete

AAMC StandardizedImmunization Form

(do not include copies of records unless requested)

3. Documentation of malpractice insurance in the amount of $1 million per occurrence and $3 million aggregate must be provided

4. Copy of health insurance (front and back of health insurance card) must be provided

Section 1. To be completed by the student. Please return original application and supporting documentation to the address listed

below. Faxed documents will not be accepted unless directed by the Division of Clinical Education.

STUDENT’S NAME

PHONE

E-MAIL

(

)

COMPLETE MAILING ADDRESS

NOTE TO APPLICANT: Applications will not be processed until after DUCOM students have been scheduled (May 1st).

Housing is not provided. Meals may be purchased in the hospital cafeteria. Six-weeks notice is required for dropping an approved

elective. Elective fees are non-refundable for confirmed rotations.

Section II: To be completed by the Dean’s Office at the Applicant’s School (**No modifications may be made to wording in

this section**)

Name of Student’s Medical School:

Student’s Medical School Address:

At the time of the elective, the student will be in the _______ year of a _______ year curriculum.

At the conclusion of the elective a report/evaluation

will

will not

be required.

I certify all of the above and that

a. the student is in good standing and has not been the subject of any non-academic disciplinary action while enrolled in our

medical school, and

b. Professional liability insurance in the amount not less than $1 million per occurrence and $3 million aggregate will be in effect

while the student is participating on rotation (documentation required), and

c. Personal health insurance will be in effect while the student is participating in the elective (documentation required), and

d. Our medical school will take financial responsibility for any reasonable accommodations required by our student if s/he has a

documented disability and requires such accommodation services, and

e. Our medical school shall defend, indemnify, and hold harmless the student’s assigned clinical training sites and Drexel

University College of Medicine, their faculty, students, employees and agents from and against any and all claims, losses,

liabilities, or expenses of any type whatsoever to the extent that such may arise due to the student’s negligent or intentional acts or

omissions while participating in the elective.

Name (printed), Title and Signature of Dean of Students or Designee

Date

Telephone(

)

Facsimile(

)

Revised

06/05/07 OGC Rev; 06/24/11 ; VSAS 09/06/2013

Supplemental Vsas Application For 4th Year Clinical Elective By A Visiting Student Page 2

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