International Away Elective Clerkship Approval Request

Last Name:*

Your legal family/last name.

First Name:*

Your legal first name.

Stanford ID #:*

8 digit university ID number.

Stanford Email Address:*

My School of Medicine Academic Advising Dean is:*

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I have obtained pre-approval to participate in the international elective clerkship from my Advising Dean.*

I have been accepted by the international institution/program to participate in the away clerkship.*

International Institution/Program's Name:*

Institution's Country Location:*

Country's Travel Risk Level:*

International Elective Clerkship Name:*

Stanford equivalent clerkship (department code & number, e.g. PEDS 312W):*

Elective Clerkship Start Date:*

Elective Clerkship End Date:*

Elective Clerkship Weeks:*

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Send me a copy of my responses