Visiting Resident Rotation Request Form

Instructions: This is a secure site. Please complete the information below.

*Indicates required information

Your Contact Information

Name of Resident *

Current Level of Training (PGY) *

Email Address *

Phone *

Your Program

Current Residency Program *

Year in Program *

Program Coordinator Name *

Program Coordinator Email*

Desired Rotations

Rotation Requested (1st Preference) *

Rotation Requested (2nd Preference)

Rotation Requested (3rd Preference)

Availability to Rotate

Instructions: List all available dates for your desired rotation(s) in the boxes below. Dates must include start and end dates in the format of MM/DD/YYYY-MM/DD/YYYY.

Requested Dates (1st Preference) *

Requested Dates (2nd Preference)

Requested Dates (3rd Preference)

Rotation Supervisor

Approval of Supervising Physician(s) already obtained? *

Yes

Full Name of Supervising Physician(s) at McLaren

Captcha*

Bay Region	Flint
Greater Lansing	Macomb
Oakland