Kettering Medical Education | Kettering Health

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* Name:
Phone:
Date of Birth:	* Email:

Current Address:

City:	State: Zip:
Phone:
Important: Where we can reach you in the summer?
* Phone # and/or email:
* Undergraduate institution you attended:
* Emergency contact & phone number:
Need a room for externship: Yes No
Need a car for externship: Yes No A valid driver's license and insurance coverage is required to use the Med Ed loaner car

Behavioral Health 0 1 2 3 4 5	Cardiology/Cath Lab 0 1 2 3 4 5
EKG/ECHO 0 1 2 3 4 5	Hematology/Oncology 0 1 2 3 4 5
HIV Clinic/Infectious Diseases 0 1 2 3 4 5	Pulmonary/ICU 0 1 2 3 4 5
Radiology 0 1 2 3 4 5

Summer Externship Application