STSG Internship/Rotation Application Form

FEES (Note subject to change):

Rotation fee = $300 for on-going work at CMHH and preceptor time
Apartment = Estimated at $150 per month, paid directly to apartment owner in Santo Domingo. Utilities are around $15 per month.
Travel Medical Insurance (TMI) = $50 app fee + $10.50 per week (Charged per week, not prorated per day)
Malpractice insurance = $4.70 per day
Airport arrival taxi = $35 (Pay directly to taxi driver)
Hostel in Quito = $20 per night (Pay directly at hostel)
Taxi from Quito to Santo Domingo = $15 - $60 (Depends on amount of luggage participant is taking)
Daily bus or taxi to worksite = 50 cents to $4, depends if bus or taxi.
Airport departure taxi = $28 (Pay directly to taxi driver)

Please note: All fees are approximate and subject to change at any time.

1 Start 2 Academic Information 3 Complete

Full Name *

Home Address *

Email Address *

Cell Phone *

Year Requested *

Month Requested *

Day Requested *

Will you receive any academic credits? *

If yes, who is your faculty course director?

If yes, what is the course name and number?

If no, what are your goals and objectives?

Will you be performing clinical activities (direct patient care) as part of this rotation?

If yes, what is your professional license number?

If yes, what is the scope of practice and supervision needed per faculty course director?

Will you be performing research as part of this rotation

Do you have funding for this internship?

If yes, what is the source and amount of funding?