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

Observership Form

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

* 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:

Observership
IP Observership (2 are required)

Eligible Clinical Disciplines:

If you have selected "IP Observership" or "Other" as the eligible clinical discipline, please provide details of the observership below:

Organization Contact Information: (Required fields are marked with '*') Please provide as much information 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) weeks 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.

I have read and agree to the procedures and regulations of the Student Observership policy.