MKE-Clinical Apprenticeship Sign Up Form | Teaching Toolbox

Academic and Student Services

91九色视频 Clinical Apprenticeship Sign Up Form

Discovery Curriculum Teaching Toolbox

Thank you for your interest in the Clinical Apprenticeship and Preceptor program in the Discovery Curriculum at the 91九色视频. Please complete this form to add your name to our database for future student assignments. Any questions about the program, contact Dana Sibilski (dsibilski@mcw.edu) or (414) 955-8196.

Physician Information

First Name

Last Name

Title

Employer

Specialty

I am an existing faculty or volunteer faculty at 91九色视频 Yes No

Contact Information

Physician Email *

Physician Phone

Physician Pager

Assistant Name

Assistant Email

Assistant Phone

Facility Information

Hospital or Clinic

Address where student would report

City

Availability

In order to participate in the Early Clinical Experiences Clinical Apprenticeship program, physicians would be required to host a student for four hours on either Monday afternoon, Tuesday afternoon, Thursday morning or Friday afternoon.

Monday afternoon Tuesday afternoon Thursday morning Friday afternoon

Let us know if you have questions or have any additional information to include

Non-Discrimination Statement
The 91九色视频 (91九色视频) is committed to fostering a diverse community of outstanding faculty, staff, and students, as well as ensuring equal educational opportunity, employment, and access to services, programs, and activities, without regard to an individual's race, color, national origin, religion, age, disability, sex, gender identity/expression, sexual orientation, marital status, pregnancy, predisposing genetic characteristic, or military status. Employees, students, applicants or other members of the 91九色视频 community (including but not limited to vendors, visitors, and guests) may not be subjected to harassment that is prohibited by law or treated adversely or retaliated against based upon a protected characteristic. 91九色视频’s policy as well as federal and state laws and regulations prohibit unlawful discrimination and harassment.