Miami Children's Hospital
Miami Children's Hospital NI IRIS Excel Block
Resident/Fellow Application Form Badge Access Meal Card
3100 SW 62ND Avenue, Miami, Florida 33155-3009 Image#______ Badge#______
Medical Education: (305) 666-6511 x2574 Initial______
Write clearly and fill in all blanks. If you return to MCH after completing your first rotation, you must still fill out the “short form”. Thank you.
Date: _____ /____ / _______ Date of Birth: _____ /____ / _______
(Month) (Day) (Year) (Month) (Day) (Year)
|Check One |
|MD DO |
|DMD DDS |
Name: __________________________________________________
(LAST NAME) (FIRST NAME) (MIDDLE NAME)
SOCIAL SECURITY# ___ ___ ____ -- ____ ___ -- ____ ____ ____ ____
Scheduled rotation at Miami Children’s Hospital:
| |
|Check One |
|Rot. Resident |
|Rot. Fellow |
| |
|From: _____ / ____ / ____ Through: _____ / ____ / ____ |
|(Month) (Day) (Year) (Month) (Day) (Year) |
|(Date when scheduled to leave) |
|Department at MCH: _______________________________ |
|Program Year (PRG): _______ (In current rotation/program) |
| |
|Total # of years in ACGME training (PGY):_______ |
| |
|Primary Hospital of Training: _______________ (accredited program sponsor) |
| |
|Current training program at primary hospital: _____________________ |
| |
|Initial training program: ______________________________________ |
|If Current training differs from Initial training please select reason: |
|Changed Program |
|Other __________________________________________ |
|(Is this Base Year a simultaneous match?) |
|Clinical Base Year training program_____________________ Yes No |
Previous training and/or employment since medical school graduation date:
|Employer/Training Facility Name |City/State/Country |Employment Dates |Residency Program Name and/or Title |
| | |From |To | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
Page 1 of 2 H:\Rotating Residents\Rotating Signup forms\Resident & Fellow Registration Form (Revised 8-3-06).doc
Education:
Medical/Dental School: _________________________________
Country: ___________________________ State: ___________
Date Graduated: ______ /_____ / _______
(Month) (Day) (Year)
Contact Information:
Address: _____________________________________________
City: _____________________ State: _______ Zip: __________
Email: _____________________________
Telephone: (_____)________________ Cell: (_____)________________
Pager: (_____)________________
Emergency Contact: ___________________________________
Relationship: __________________ Telephone: (____)______________
I certify that the information above is correct to the best of my knowledge. Resident/Fellow Signature: _______________________________
Page 2 of 2 H:\Rotating Residents\Rotating Signup forms\Resident & Fellow Registration Form (Revised 8-3-06).doc
-----------------------
~STAFF ONLY~
Check-off list:
← Form complete
← Copy of ECFMG attached, if applicable
← Copy of licensure attached (from )
← Resident/Fellow received Notice of Privacy (for HIPAA)
← Attached rotation schedule matches scheduled dates
Date of completion*: _____________ *rotation cannot begin until check-off list is complete
Medical Education Department Signature: Resident/Fellow’s Signature:
______________________________________ ____________________________________
Medical Education Approval: ____
(initials)
................
................
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