Clerkships Application

Thank you for your interest in a clerkship at the University of Wyoming Family Medicine Residency Program at Casper/Community Health Center of Central Wyoming.

To best maximize the educational experience, we are able to take only two students at a time. Please provide the following information to help us organize our program schedule. Although we ask for a first and second choice of dates, if there is only one date that you can come, fill in that blank only.

Thank you!

Name: * = required
Email: * = required
Address:
City:
State:
Zip:
Phone:
School:
Year:
Dates you would like to come:
1st Choice:	to
2nd Choice:	to
Area in medicine of primary interest to you:
Explain briefly your interest in the Casper program and Wyoming:
Other information you may feel would help us, such as spouse coming with you, assistance with housing, etc.: