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:

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:

mm/dd/yyyy

Elective Clerkship End Date:

mm/dd/yyyy

Elective Clerkship Weeks:

Send me a copy of my responses

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