Student Rotation Request

Please complete this form to request your rotation.You may request up to 3 rotations per form. All requests must be submitted at least 60 days prior to the start of the rotation. Once your request is received, you will be notified by email if it has been approved. Rotations will not be scheduled until all required information is received. Once a rotation is confirmed you are required to give a 90-day notice to cancel or your school will be notified. Please note Internal Medicine Sub-I rotations may not be canceled after confirmed. Please direct any questions to Brenda Duquette, Medical Student Liaison: Brenda_Duquette@mercy.com.

First Name*

Your Email*

Last Name*

Address*

Last 4 digits of SS# or Passport#*

City

State

Zip

DOB*

Phone*

Step 1/COMLEX Score*
**Minimum score for Emergency Medicine rotation: 230 For Step 1, 550 for COMLEX

Medical School Name*

Anticipated Graduation Date*

Rotation Requested

Rotation Requested*

Dates Requested*

Rotation Requested

Dates Requested*

Rotation Requested

Dates Requested*

Questions or Comments (you may request alternate date options here)

Programs