UNIVERSITY OF SOUTH ALABAMA COLLEGE OF MEDICINE
Visiting Student Application

Section I: To be completed by the Student and Dean's Offices of Student's School
 

Name of Applicant                                                                          Date 

Address 

EMAIL ADDRESS

Parent Medical School 

Address 

Title of Elective Course You Wish To Take:
 

First Choice 

Block (or dates) 

Second Choice 

Block (or dates) 

Third Choice 

Block (or dates) 

Students may list his/her second and third choice dates for the above course, or another elective course choice and dates.

Statement of Dean from Parent Medical School: I certify:
the above named student is in good standing at the 


School of Medicine and has permission to study for credit at the University of South Alabama College of Medicine during the period listed above.
 


     Signature of Dean or Associate Dean of Parent Medical School

Statement of the Visiting Medical Student: I am aware of the following:
 

  1. Evaluation of my performance while studying at the University of South Alabama College of Medicine will be based on the same criteria as those used to judge matriculated South Alabama students.
  2. I am not covered by University of South Alabama health insurance.
  3. I must obtain Professional Liability Insurance (malpractice) on the first day of my visiting rotation unless I have documented existing malpractice coverage.
  4. I am requested to call as soon as possible if my situation changes and I am unable to take the indicated elective course.



    Signature of Visiting Student

Upon completion of the form to this point, the potential visiting student should return it to:

Betsy D. Bennett, M.D., Ph.D., Vice Dean
Student Affairs & Medical Education
University of South Alabama Medical Center
2451 Fillingim St., Mastin 202
Mobile, AL 36617-2293

Section II: To be completed at the University of South Alabama

Statement of University of South Alabama College of Medicine Sponsor:

I understand that there is an open student slot in the elective                                                                                         Block (or date)                                                                  and agree to sponsor and advise this visiting student during his or her visit to South Alabama.  I understand that this student may not replace a South Alabama student in the above elective; i.e. more than the maximum number of students listed in the Elective Catalog cannot be scheduled.
 


Signature of Elective Course Leader, Department Chair,
Department Scheduling Secretary or Authorization by telephone
Approval: This student has been accepted as a visiting student.  He or she should report to:

Person:                                                                                               Place: 

Date and Time: 

Vice Dean's Office