School of Medicine
Faculty of Health Sciences Queen's University
 
Undergraduate Medical Education

Observership Registration Form

All Forms must be submitted prior to the commencement of any activity. You must also submit the Attendance Form within three (3) months from the date of completion of the activity. Access to the Attendance Form will be provided upon submission of the Registration Form.


* Student First Name:
* Student Last Name:
*Graduation Year:
*Qlink Email Address:
*Activity Start Date:        
*Activity End Date:        

Please check the appropriate option pertaining to your activity:

Activity Type

Critical Enquiry
Observership

 

Discipline

Anesthesiology
Critical Care Medicine
Diagnostic Radiology
Emergency Medicine
Family Medicine
Geriatrics
Medicine
Obstetrics & Gynecology
Oncology
Ophthalmology
Otolaryngology
Pediatrics
Pathology
Palliative Care
Physiatry
Psychiatry
Surgery
Urology
Other

ORGANIZATION CONTACT INFORMATION: (Required fields are marked with '*'. Please provide as much info as possible.)

Organization:
* Supervisor/Administrator:
* Address Line 1:
Address Line 2:
* City:
* Prov/State/Country:
Postal Code:
Phone:
Fax:
* Supervisor/Administrator Email:

(Form cannot be processed if all required information is not completed)

By sending this approval form I certify that the above information has been filled out to the best of my knowledge. I am aware that in order for this activity to be recognized by the UGME office as completed, I must submit an Attendance Certificate within three (3) months from the date of completion of this activity. I understand that if this is an International activity it is my responsibility to follow the International process guidelines located on the UGME website.