2023 Summer Externship Application

Co-Sponsored By: The Family Health Foundation of Missouri and The American Academy of Family Physicians Foundation. The deadline to apply is Monday, March 13, 2023.

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* 1. Student Information

Name

Birthdate

Mailing Address

City

State

ZIP Code

Email Address

Phone Number

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* 2. Name of the Missouri Medical School You Attend

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* 3. Current Year of Medical School

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* 4. Preference for Externship Location

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* 5. Please list any professional healthcare or student organizations besides MAFP that you are a member of.

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* 6. Please select the number that reflects your current level of interest in entering a family medicine residency program.

0 (Not interested)

10 (Certain)

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 7. Please explain why you are interested in family medicine (in 500 words or less). Or attach a file.

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* 8. Please explain why you want to participate in the Student Externship Program (in 500 words or less). Or attach a file.

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* 9. Upload Other Supporting Documents (In one file)