ࡱ> nqm abjbj,(,( tNBNB# JJJ^^^^^{ jllll'D,"%`]Jk"kkll95 k8lJlk2.@7lsM:K 0{ &%%.J.hkkkkkk{ %kkkkkkkkk* :   Rural Site Request Form  Third Year Medical Students Name:  FORMTEXT      ID#:  FORMTEXT      Phone:  FORMTEXT       Ualberta Email:  FORMTEXT       Rural Family Medicine Dates (dd / mmmm / yyyy ):  FORMTEXT Start Date to  FORMTEXT End Date My top six choices for my first / only four (4) week location are (See below for possible ruralcommunities):**PLEASE NOTE THAT THIS REQUEST WILL ONLY BE CONSIDERED IF YOU HAVE EXTENUATING CIRCUMSTANCES FOR A CERTAIN COMMUNITY THAT YOU WOULD LIKE TO BE PLACED IN** 1.  FORMTEXT      2.  FORMTEXT      3.  FORMTEXT      4.  FORMTEXT      5.  FORMTEXT      6.  FORMTEXT       Rural Communities are:Athabasca Fort McMurray Ponoka VermilionBanff Hinton Redwater VikingBarrhead Innisfail Rimbey WabascaBellevue Jasper Rocky Mountain House WestlockBonnyville Killam Smoky Lake WetaskiwinCanmore Lac La Biche Spirit River WhitecourtDrayton Valley Lamont St. PaulEdson Lethbridge Trochu  FORMTEXT      Fairview Peace River Vegreville  FORMTEXT       Accommodation:Office of Rural & Regional Health will provide free accommodations during your rural rotation. Please note that the student will be held personally responsible for any damages caused to the premises after their move in. It is the students responsibility to leave the accommodations in the same condition as when they moved in. Extra cleaning fees will be the responsibility of the occupant. I allow the Office of Rural & Regional Health to release my e-mail address to the RPAP Accommodation Coordinator for the sole purpose of providing accurate and timely accommodation to me if required, in accordance with the FOIPP provisions.  FORMCHECKBOX No  FORMCHECKBOX  Yes  lnz|ªuU4%hwhwCJOJQJaJ@jhwhw5B*CJOJQJU^JaJmHnHphu>jhwhw5:B*CJOJQJU^JaJph/hwhw5:B*CJOJQJ^JaJph8jhwhw5:B*CJOJQJU^JaJph/hwhw5:B*CJOJQJ^JaJph33'hg1hw5:B*OJQJaJph33%hg*5:B*CJOJQJaJph+hDhw5:B*CJOJQJaJph ln  \ UH 0$Ifgdw{kd$$Ifl0y0*y t03333333333330*644 lalytw +$If^gdw $Ifgd[%gdw$-DM 33a$gdw 4 6 J L N ͯvrvTv6;jhwhw5B*CJOJQJU^JaJph;jvhwhw5B*CJOJQJU^JaJphhw/hwhw5:B*CJOJQJ^JaJph33@jhwhw5B*CJOJQJU^JaJmHnHphu;jthwhw5B*CJOJQJU^JaJph,hwhw5B*CJOJQJ^JaJph5jhwhw5B*CJOJQJU^JaJphN X Z \ ` l Ĭ~~jM5/hwhw5:B*CJOJQJ^JaJphff8jhwhw5:B*CJOJQJU^JaJphff&hwhw5:CJOJQJ^JaJ)hh5:B*CJOJQJ^JaJph33)h1 5:B*CJOJQJ^JaJph33hw/hwhw5:B*CJOJQJ^JaJph335jhwhw5B*CJOJQJU^JaJph@jhwhw5B*CJOJQJU^JaJmHnHphu \ ^ `  ql_ $Ifgdhgdwkd^$$IflF 0*   t03333333333330*6    44 lalytw    åÍu]=å.hwhwCJOJQJaJ>jhwhw5:B*CJOJQJU^JaJphff/hwhw5:B*CJOJQJ^JaJphff/hwhw5:B*CJOJQJ^JaJph33/hwhw5:B*CJOJQJ^JaJph:hwhw5:B*CJOJQJ^JaJmHnHphffu8jhwhw5:B*CJOJQJU^JaJphff>jhwhw5:B*CJOJQJU^JaJphff     $Ifgd[%gdwjkd$$Ifl0*0* t03333333333330*644 lalytw    [ " # $ % ( ) 3 ־֯֐{֨fN;%hwhwB*CJOJQJaJph33.jhwhwB*CJOJQJUaJph33(hwhw5B*CJOJQJaJph33(hh56:B*CJOJQJaJph.hwhw56:B*CJOJQJaJph h,5hwhwhwB*CJaJph.hwhw56:B*CJOJQJaJph+hwhw5:B*CJOJQJaJphhwhY+hwaJ hY+hw $ ~ $Ifgd[%wkd$$Ifl0*0*  t 3303333333333330*644 lalp 33ytw$ %  < j zm` $Ifgdw 0$Ifgdw t$Ifgdwwkd%$$Ifl0*0*  t 3303333333333330*644 lalp 33ytw3 4   * , . 8 : < B D X Z \ f h j l r t Ͱ͈͛mͰ^͈CͰ^< h,5hw4jhwhwB*CJOJQJUaJph33hwhwCJOJQJaJ4j4hwhwB*CJOJQJUaJph33%hwhwB*CJOJQJaJph33(hwhw5B*CJOJQJaJph339jhwhwB*CJOJQJUaJmHnHph33u.jhwhwB*CJOJQJUaJph334jhwhwB*CJOJQJUaJph33j l qdWJ $Ifgdw ,$Ifgdw l$Ifgdwkd $$IflFX0*XX t03333333333330*6    44 lalytwt ѹx]xB4jhwhwB*CJOJQJUaJph334jhwhwB*CJOJQJUaJph33(hwhw5B*CJOJQJaJph33hwhwCJOJQJaJ9jhwhwB*CJOJQJUaJmHnHph33u.jhwhwB*CJOJQJUaJph334jhwhwB*CJOJQJUaJph33%hwhwB*CJOJQJaJph33 * qllc $Ifgd[%gdwkd $$IflFX0*XX t03333333333330*6    44 lalytw ( * , > @ B \ ` l n {{{le{R{R{C< h,5hhhihhB*CJaJph33%hihhB*CJOJQJaJph33 h,5hhihB*CJaJph33hhB*CJOJQJaJph33%hihB*CJOJQJaJph33%hihB*CJOJQJaJph33hgVB*CJOJQJaJph33hwhwB*CJaJph+hwhw5:B*CJOJQJaJphh,5hwCJaJhwCJaJ h,5hw* , @ ^ n vi\O $Ifgdi $Ifgdh $Ifgdh $IfgdgV|kd $$Ifl:0*0*  t 3303333333333330*63344 lalp 33yti F9, $Ifgdm # $IfgdgVkdH $$Ifl\ F 0*    t03333333333330*644 lalp(yti ,kd $$Ifl\ F 0*    t03333333333330*644 lalp(yti $Ifgdh $Ifgdh (<dfxz|246RVbhz~ܮܓ4jPhihhB*CJOJQJUaJph33.jhihhB*CJOJQJUaJph33 h,5hhhihhB*CJaJph33%hihhB*CJOJQJaJph33hhB*CJOJQJaJph331  $Ifgdm # $Ifgdh $Ifgdm # $IfgdgV*:F9, $Ifgdm # $Ifgdm #kd $$Ifl\ F 0*    t03333333333330*644 lalp(yti:fz|,kdp $$Ifl\ F 0*    t03333333333330*644 lalp(yti $Ifgdm # $Ifgdh| $Ifgdm # $Ifgdh $Ifgdm # $Ifgdm #F9, $Ifgdm # $Ifgdm #kd( $$Ifl\ F 0*    t03333333333330*644 lalp(yti46,kd $$Ifl\ F 0*    t03333333333330*644 lalp(yti $Ifgdm # $Ifgdm #6Td|~ $Ifgdi $Ifgdm # $Ifgdm # $Ifgdm #~F9, $Ifgdm # $Ifgdm #kd$$Ifl\ F 0*    t03333333333330*644 lalp(yti,kd$$Ifl\ F 0*    t03333333333330*644 lalp(yti $Ifgdi $Ifgdm #2468LNPZ\^`d;͔y;u_Pu>#h5B*CJOJQJ^JaJph33hwhwB*CJaJph+hwhw5:B*CJOJQJaJphhw4j~hihhB*CJOJQJUaJph33%hihhB*CJOJQJaJph33hhB*CJOJQJaJph33 h,5hhhihhB*CJaJph33.jhihhB*CJOJQJUaJph333jhhB*CJOJQJUaJmHnHph33u4^ $Ifgdi $Ifgdm # $Ifgdh $Ifgdm #^`bdFAA8 $Ifgd[%gdwkd$$Ifl\ F 0*    t03333333333330*644 lalp(yti|X~Xzzkz (x$Ifgdw $Ifgd[%|kd$$Ifl:0*0*  t 3303333333333330*644 lalp 33ytw ۱cL/8jhwhwB*CJOJQJU^JaJph33,hwhw5B*CJOJQJ^JaJph338jThwhwB*CJOJQJU^JaJph332jhwhwB*CJOJQJU^JaJph33,hwhw>**䴳ϴ33)ww*䴳ϴ33)*䴳ϴ33#5*䴳ϴ33#*䴳ϴ33046ٳѺѸhG+ҝ7ww>**䴳ϴԱ33ww>**䴳ϴԱ33;<hwhw>*B*CJOJQJU^JaJph33,hwhw>*B*CJOJQJ^JaJph335jhwhw>*B*CJOJQJU^JaJph33U,hwhw5B*CJOJQJ^JaJph33)hwhwB*CJOJQJ^JaJph332jhwhwB*CJOJQJU^JaJph33Initial here to confirm:  FORMTEXT     I have a family that will accompany me during my rotation:  FORMCHECKBOX No  FORMCHECKBOX  Yes # of:  FORMTEXT       Adults (include self)  FORMTEXT       Children (  FORMTEXT       age child #1  FORMTEXT       age child #2  FORMTEXT       age child #3 Accommodation:Please email the completed form to Ms. Rattan Dhillon at  HYPERLINK "mailto:rattan1@ualberta.ca" rattan1@ualberta.ca or drop it off in-person at our office located within the Division of Community Engagement at 2-115 ECHA. Please note that this form is to be filled out by all students in Class of 2017 for the purpose of releasing your information to RPAP for accommodations.Accommodation: The personal information requested on this form is collected under the authority of Section 33 (c) of the Alberta Freedom of Information and Protection of Privacy Act for the purpose of administering the undergraduate Rural & Regional Rotations Program. 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