Michigan Medical Student Externship Matching Grant Funding Application

Family Medicine Foundation of Michigan's Student Externship Program is designed to stimulate interest in selecting a career as a family physician and/or pursuing research opportunities in family medicine. In addition to gaining hands-on family medicine experience, the extern and his/her family physician mentor (must be MAFP members) each receive a stipend at the end of the externship. Funding for the externship is made possible by matching grants from AAFP Foundation and Family Medicine Foundation of Michigan.

Interested students should work with their medical school to submit this application to Family Medicine Foundation of Michigan no later than Feb. 8.

Please note: If the matching grant funds are not used in the award year they must be returned to the AAFP Foundation and Family Medicine Foundation of Michigan.

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* 1. Medical School

Name of Medical School

Address

City

State

ZIP

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* 2. Medical School Contact Information

Name of Contact at Medical School

Title

Email Address

Office Phone Number

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* 3. Medical Student Contact Information

Student's Name

Year in Medical School

Email Address

Phone Number

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* 4. On a scale of 0-10, what is the student's current interest in Family Medicine?

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* 5. Is this student actively involved in the medical school's Family Medicine Interest Group?

Yes

If you answered yes, and this student holds a leadership position in the FMIG, please list the leadership position:

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* 6. Family Medicine Mentor/Preceptor Contact Information

Mentor's/Preceptor's Name and Designation

Title

Email Address

Phone Number

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* 7. Is this externship clinical and/or research in nature?

Clinical

Research

Both clinical and research

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* 8. Give a brief description of the one-on-one learning experience with a Family Medicine mentor/preceptor that this externship will provide the medical student.

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* 9. How many weeks will this externship program last? (Please note that the AAFP Foundation requires that the medical student externship must offer a research and/or clinical experience that is at least four weeks in duration.)

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* 1. Medical School

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* 2. Medical School Contact Information

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* 3. Medical Student Contact Information

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* 4. On a scale of 0-10, what is the student's current interest in Family Medicine?

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* 5. Is this student actively involved in the medical school's Family Medicine Interest Group?

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* 6. Family Medicine Mentor/Preceptor Contact Information

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* 7. Is this externship clinical and/or research in nature?

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* 8. Give a brief description of the one-on-one learning experience with a Family Medicine mentor/preceptor that this externship will provide the medical student.

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* 9. How many weeks will this externship program last? (Please note that the AAFP Foundation requires that the medical student externship must offer a research and/or clinical experience that is at least four weeks in duration.)

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* 10. Please identify partners, if any, that will collaborate in this externship: