2020 RREMS Student Interest Form

Each student must first complete an Interest Form identifying their preferred sponsor site/s by December 4, 2019.
Students are responsible for identifying their own mentors from the AAP's approved list of sponsor sites. Applications will not be accepted unless the sponsor site has been approved prior to the student’s application.
Please do not wait to contact sponsor sites if you are interested in participating.
Allow at least one month to complete the application process.

Question Title

* 1. Please provide the following information:

Name of student:

Student's Medical School:

Student's Mailing Address

City/Town:

State/Province:

ZIP/Postal Code:

Student Contact Email:

Student Contact Phone:

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* 2. Year in Medical School:

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* 3. Proposed Sponsor Site 1

Proposed Sponsor Institution

Proposed Mentor

Area of Interest for Research Proposal

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* 4. Proposed Sponsor Site 2

Proposed Sponsor Institution

Proposed Mentor

Area of Interest for Research Proposal

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* 5. Proposed Sponsor Site 3

Proposed Sponsor Institution

Proposed Mentor

Area of Interest for Research Proposal

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* 6. Proposed Sponsor Site 4

Proposed Sponsor Institution

Proposed Mentor

Area of Interest for Research Proposal

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* 7. Please complete the following information about the availability of PM&R programs at your medical school. Select all that apply.

There is a PM&R Department

There is a PM&R Residency Program

There is a mandatory PM&R clerkship

None of the above

Comments:

Question Title

* 8. How did you find out about the RREMS program? Select all that apply.

AAP Website

AAP Newsletter

AAP eBrief

PM&R SIG

Classmate/Resident

Medical Association (Other than AAP)

Other (please specify)